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Diseases  of  Children 


AND    THEIR 


HOMEOPATHIC  TREATMENT. 


7 


A  Text-Booh  for  Students,  Colleges,  and  Praditionen 


ROBERT  N. 


"^K. 


OOKER,  M.D., 


Prfoesfor  of  Diseases  of  Children   in   the   Chicago  Homeopathic  Medical    College;  Ex- 
President  of  the  American  Pedological  Association;  Ex-President  of  the  Illinois 
Association  of  Homeopathic  Physicians;  Ex-President  of  the  Chicago 
Academy  of  Homeopathic  Physicians  and  Surgeons ;  Ex- 
Chairman  of  the  Bureau  of  Pedology  of  the 
American  Institute,  etc.,  etc. 


CHICAGO 

GROSS  AND  DELBRIDGE 

No.  48  Madison  Street 
1895 


\MS9lC)0 

1  ?iy 


Copyright.  1894, 
QUOSS    &    DBLBRIDGE. 


TO 

MARIA  M.  GROSS,  M.  D. 

WHO    WAS    AMONG    THE     FIRST    OF    HER     SEX    TO 

DEMONSTRATE    WOMAN's    FITNESS 

FOR     THE     STUDY     AND     PRACTICE     OF     MEDICINE,    AND     WHOSE 

ADVICE    AND    COUNSEL 

HAVE    OFTEN    BEEN    OF    GREAT    VALUE    TO    THE    WRITER 

IN    CRITICAL     CASES,    THIS 

WORK    IS    AFFECTIONATELY    DEDICATED    BY 

HER    BROTHER, 

THE  AUTHOR. 


(Hi) 


A 


PREFACE. 


The  need  of  a  new  and  comprehensive  treatise  on  Pediatrics, 
adapted  to  the  wants  of  students  and  practitioners  of  the 
Homeopathic  School  of  Medicine,  has  long  been  recognized. 
The  literature  of  the  older  school  is  replete  with  manuals  of 
the  highest  order,  and  cyclopedias  of  rare  merit ;  but  our  own  is 
almost  barren  in  this  direction.  In  every  other  branch  of  medi- 
cine and  surgery,  our  authors  have  been  numerous  and  prolific. 

In  Pediatrics  alone,  are  we  behind  our  confreres.  This  state 
of  affairs  cannot  be  explained  on  the  ground  of  indifference,  or 
in  any  way  satisfactorily,  except  that  our  many  able  writers  in 
this  specialty,  have  each  been  waiting  for  the  other  to  take  the 
initiative  and  assume  the  burden  and  responsibility  of  author- 
ship. The  writer  began  the  preparation  of  the  present  volume 
more  than  five  years  ago,  but  its  progress  was  suspended  for 
several  years,  owing  to  current  rumors  that  others  quite  as 
capable  were  actively  engaged  in  a  similar  undertaking.  As 
these  rumors  failed  to  materialize,  the  demand  for  a  new  book 
on  the  diseases  of  children  and  their  homeopathic  treatment, 
became  imperative,  and  the  work  was  resumed. 

The  labor  involved  in  the  preparation  of  an  acceptable  trea- 
tise, covering  the  entire  field  of  Pedology,  seemed,  at  first,  to  be 
prohibitory,  in  the  midst  of  a  busy  every-day  practice,  and  the 
exacting  duties  of  college  work;  but  the  enthusiastic  proffers  of 
aid  from  so  many  professional  friends,  who  had  already  become 
widely  known  as  authors  and  teachers,  gave  all  needed  encour- 
agement, and  the  work  has,  with  their  help,  been  carried  to 
completion  in  a  most  agreeable  manner.  The  author's  thanks 
are  hereby  given  to  Prof.  L.  C.  Grosvenor,  for  his  chapter  on 
the  Sanitation  of  the  Nursery ;  to  Prof.  J.  H.  Buffum,  for  the 
chapters  on  the  Eye  and  Ear;  to  Prof.  E.  M.  Hale — Affections 

(V) 


101 


PRE  FA  CE. 

of  the  Heart ;  and  to  Prof.  Clifford  Mitchell,  for  his  admirable 
contribution  on  the  Disorders  of  the  Urinary  Tract. 

Thanks  are  also  due  to  Profs.  N.  B.  Delamater  and  S.  N. 
Schneider  for  the  section  on  Nervous  diseases. 

Finally,  the  author  desires  to  express  his  obligations  to  the 
numerous  writers  of  both  schools  of  medicine,  whose  contribu- 
tions to  the  literature  of  this  subject  have  been  constantly  con- 
sulted, and  at  times  freel^'^  drawn  upon,  due  credit  being  given 
in  the  text  as  called  for. 

The  diseases  of  children  are  practically  the  same  the  world 
over,  and  they  have  been  so  often,  so  accurately,  and  exhaus- 
tively described,  that  a  distinctively  original  work  on  Pedology 
is  scarcely  possible. 

The  aim  of  the  writer  has  been,  not  so  much  to  improve  on,  or 
vary  the  descriptions  of,  disease  phenomena,  affecting  infants 
and  children,  as  set  forth  in  other  and  standard  treatises;  nor 
to  add  to,  or  find  fault  with,  accepted  theories  of  etiology  and 
pathology,  but  rather  to  condense  our  present  knowledge, 
opinions,  and  theories,  and  gather  together  the  best  therapeu- 
tic and  hygienic  measures  for  the  relief  of  infantile  maladies. 

That  portion  of  the  work  for  which  the  writer  is  more  espe- 
cially responsible,  is  the  outgrowth  of  thirty  years'  experience 
as  a  medical  practitioner,  more  than  half  of  which  period  has 
been  spent  as  a  teacher  of  Pediatrics.  It  is  not  presumption, 
therefore,  to  hope  that  the  volume  will  be  found  not  without 
merit,  and  that  it  will  be  acceptable  and  helpful  to  the  medical 
student,  and  a  welcome  accession  to  the  working  library  of  the 
busy  doctor. 

R.  N.  T. 

Chicago,  November  i,  1894. 


CONTENTS. 

^ % 

PART    I. 

CHAPTER     I. 
Introductory i-iS 

CHAPTER     II. 
Therapeutic  Hints .        .        .        19-25 

CHAPTER     III. 
Diseases  and  Accidents  Immediately  Following  Birth  .         26-31 

CHAPTER     IV. 
Food  and  Feeding 32-45 

CHAPTER     V. 
Food  and  Feeding  (continued) 4^-65 

CHAPTER     VI. 
Nursery  Hints 66-73 


PART    II. 

Diseases  of  the  Eye  and  Ear. 

chapter    i. 

Diseases  of  the  Eye 74-114 

CHAPTER     II. 
Diseases  of  the  Ear 115-151 

PART    III. 

Diseases  of  the  Digestive  Organs. 

chapter    i. 

General  Considerations 152-164 

(vii) 


viii  CONTENTS. 

CHAPTER     II.  PACK 

ESOPHAGITIS 165-170 

CHAPTER     III. 
Congenital  Dyspepsia 171-178 

CHAPTER     IV. 
Diarrhea 179-199 

OHAPTER     V. 
Constipation 200-206 

CHAPTER     VI. 

Intestinal  Parasites 207-217 

CHAPTER     VII. 

Intestinal  Obstruction 218-221 

CHAPTER     VIII. 
Dentition 222-232 


PART    IV. 

Diathetic  Diseases. 

chapter   i. 

General  Considerations 233-234 

CHAPTER     II. 
Rachitis 235-249 

CHAPTER     III. 
Acute  Tuberculosis — Tabes  Mesenterica  .        .        .        250-256 

CHAPTER     IV. 
Scrofula 257-266 

CHAPTER     V.      ■ 
Infantile  Syphilis 267-271 

PART    V. 

The  Eruptive  Fevers. 

chapter    i. 

General  Considerations 272-275 

/ 


CONTENTS.  ix 

CHAPTER     II.  PAGE 

Measles 276-283 

CHAPTER     III. 

ROTHELN 284-288 

CHAPTER  IV. 
Scarlet  Fever — Regular,  Irregular,  Malignant  .        .        289-316 

CHAPTER  V. 
Roseola 317-321 

CHAPTER  VI. 
Varicella,  Vaccinia,   Vaccination,   Virus,    Revaccina- 

TION 322-335 

PART    VI. 

Non-Eruptive  Contagious  Diseases. 

chapter    i. 

Diphtheria — Laryngeal    Diphtheria,    Intubation    and 

Tracheotomy 336-370 

CHAPTER  II. 
Whooping  Cough — Pertussis 371-379 

CHAPTER  III. 
Parotiditis — Mumps 380-382 

PART    VII. 

Affections  of  the  Heart. 

chapter    i. 

Position,  Anatomy  and  Fetal  Circulation        .        .        .        383-386 

CHAPTER  II. 
Congenital  Diseases  of  the  Heart  : 

Cyanosis,  Valvular  Diseases,  Endocarditis,  Pericarditis  .         387-419 


PART    VIII. 

Disorders  of  the  Urinary  Tract. 

chapter    i. 

The  Urine  of  Infancy  and  Childhood  : 

Collecting,  Examination,  Specific  Gravity,  Sediment        .        420-434 


X  CONTENTS. 

CHAPTER     11.  PAGE 

The  Urine  in  Various  Disorders  of  Childhood      .        .        435-438 

CHAPTER     III. 
Acute  Nephritis,  Subacute  Nephritis 439-450 

CHAPTER     IV. 
Pyuria  and  Hematuria .        .        45^-455 

CHAPTER     V. 
Cancer  in  the  Urinary  Tract: 

Cancer  of  Prostate,  Tumors  of  the  Bladder,  Renal  Cancer. 

Sarcoma  of  the  Kidney,  Hydronephrosis  .         .         .         456-461 

CHAPTER     VI. 
Calculus  in  the  Urinary  Passages 462-463 

CHAPTER     VII. 

Uricemia 464-469 

CHAPTER     VIII. 
Diabetes  Mellitus 470-488 

CHAPTER     IX. 
Diabetes  Insipidus 489-493 

CHAPTER     X. 
Enuresis *. 494-507 


PART    IX. 

Diseases  of  the  Respiratory  Organs, 
chapter   i. 

General  Considerations  : 

Collapse  of  Lung,  Dyspnea,  Percussion,  Cough 
CHAPTER     II. 

CORYZA        

CHAPTER     III. 

Epistaxis 

CHAPTER     IV. 

TONSILITIS 

CHAPTER     V. 

Laryngitis,  Spasmodic  Laryngitis,  Chronic  Laryngitis, 
Laryngismus  Stridulus 


508-514 
515-518 
519-523- 
524-533^ 

534-53/ 


CONTENTS.  xi 

CHAPTER     VI.  PAGE 

Acute  Membranous  Laryngitis 538-55^ 

CHAPTER     VII. 

Pneumonitis 552-5^4 

CHAPTER     VIII. 

Bronchitis,  Capillary  Bronchitis 565-576 

CHAPTER     IX. 

Asthma — Emphysema 577-582 

CHAPTER     X. 

Atelectasis 583-587 

CHAPTER     XI. 

Pulmonary  Phthisis     .        . 588-594 

CHAPTER     XII. 
Pleurisy 595-603 

PART     X. 

General  Diseases, 
chapter   i. 

Cerebro-Sfinal  Fever 604-614 

CHAPTER     IL 

Infantile  Typhoid  Fever  : 

Enteric  Fever,  Infantile  Remittent  Fever,  Typho-Malarial 

Fever,  Typhus  Abdominalis,  Continued  Fever      .         .         615-627 

CHAPTER     IIL 
Intermittent  Fever  : 

Malarial    Fever,    Chills    and    Fever,    Miasmatic     Fever, 
Ague 628-637 

CHAPTER     IV. 

Rheumatism 638-641 

CHAPTER     V. 

Adenitis,  Lymphadenitis  : 

Non- Specific  Inflammation  of  the  Lymphatic  Glands        .        643-646 


xii  CONTENTS. 

PART    XI. 
Affections  of  the  Nervous  System. 

chapter   i.  pagk 

Introduction 647-651 

CHAPTER     II. 
Convulsions  in  Children  : 

Epilepsy 652-661 

CHAPTER     III. 
Chorea : 

St.  Vitus'  Dance 662-671 

CHAPTER     IV. 
Infantile  Tetanus  : 

Trismus  Nascentium,  Lockjaw 672-674 

CHAPTER     V. 
Paralysis  : 

Cerebral  Paralysis,  Multiple  Cerebro-Spinal  Sclerosis, 
Cerebral  Hemorrhage,  Thrombus,  Embolism,  Cerebral 
Tumors,  Spinal  Paralysis,  Potts'  Disease,  Myelitis, 
Acute  Idiopathic  Myelitis,  Chronic  Myelitis,  Anterior 
Polyomyelitis,  Spinal  Hemorrhage,  Primary  Lateral 
Sclerosis,  Pseudo-Hypertrophic  Paralysis,  Paralysis  of 
the  Portio  Dura 675-709 

CHAPTER     VI. 
Hereditary  Ataxy: 

Acquired  Locomor  Ataxy 710-712 

CHAPTER     Vn. 

Idiocy 713-717 

CHAPTER     VIII. 
Insanity  : 

Hysteria 718-728 

CHAPTER     IX. 
Disorders  of  Sleep: 

Night  Terrors 729-732 

CHAPTER     X. 

Headaches  in  Children .        .        733-734 

CHAPTER     XL 
Congestion  of  the  Brain 735-74° 


CONTENTS.  xiii 

CHAPTER     XII.  PAGE 

Meningitis,  Simple  Meningitis,  Tubercular  Meningitis  741-749 

CHAPTER     XIII. 

Hydrocephalus .  750-756 


PART    XII. 

Diseases  of  the  Skin. 

chapter    i. 

Eczema,  Crusta  Lactea,  Moist  Tetter,  Salt  Rheum      .        757-770 

CHAPTER    II. 
Psoriasis,  Psora,  Dry  or  Scaly  Tetter       ....        771-774 

CHAPTER     III. 
Miliaria   Rubra,  Red  Gum,  Strophulus,  Tooth  Rash     .         775-776 

CHAPTER     IV. 
Erythema,  Rose  Rash 777-78o 

CHAPTER     V. 
Zoster,  Herpes  Zoster,  Zona,  Shingles       ....         7S1-783 

CHAPTER     VI. 
Erysipelas,  St.  Anthony's  Fire 784-789 

CHAPTER     VII. 

Impetigo  Contagiosa .        790-792 

CHAPTER     VIII. 
Urticaria,  Nettle  Rash,  Hives       .        .        .        ,        .        .        793-797 

CHAPTER     IX. 
Trichophytosis,  Ring  Worm 798-801 

CHAPTER     X. 
Scabies,  Itch 802-805 


THE  DISEASES  OF  CHILDREN. 


PA  RT    I 


CHAPTER  I. 

INTRODUCTORY. 

The  period  of  *'  infancy,"  when  used  in  a  medical  sense,  is 
understood  as  covering  the  time  from  birth  to  the  completion 
of  first  dentition,  which  occurs  as  a  rule  when  the  child  is  about 
two  and  a  half  years  of  age. 

Childhood  covers  the  period  from  infancy  to  puberty,  which 
in  this  country  is  reached  at  an  age  of  twelve  to  fourteen. 
When  taken  together  they  constitute  an  epoch  in  human  life 
which  is  fraught  with  absorbing  interest.  Until  within  the  last 
thirty  years  no  American  medical  college  had  paid  any  special 
attention  to  the  diseases  peculiar  to  childhood ;  no  children's 
clinics  were  held,  and  all  that  the  medical  student  could  learn 
about  them  was  to  be  found  in  the  text-books  and  didactic 
lectures  on  general  practice.  Now,  however,  all  of  our  princi- 
pal medical  colleges  have  a  special  chair  of  pedology ;  special 
children's  clinics  are  deemed  as  necessary  as  any  other,  and 
numerous  large  and  comprehensive  treatises  devoted  to  this 
subject  are  among  the  most  highly  prized  volumes  in  every 
intelligent  physician's  medical  library. 

It  is  not  at  all  strange  that  this  should  be  so.  The  period 
referred  to  is  essentially  different  in  every  aspect  from  adult- 
life.  The  anatomy,  the  physiology,  the  pathology  and  the 
therapeutics  of  infancy  are  all  sufficiently  different  to  require 
special  study  and  special  knowledge  for  their  proper  under- 
standing. That  adults  occasionally  and  exceptionally  have 
diseases  that  as  a  rule  are  found  only  among  children,  does  not 
militate  against  this  statement. 

One  might  practice  medicine  for  a  lifetime  among  adults 
without  meeting  a  typical  case  of  measles,  or  scarlet  fever,  or 
diphtheria,  nor  would  he  know  anything  about  the  aberrations 

(1) 


2  THE  DISEASES  OF  CHILDREN. 

of  development.  Under  such  circumstances  he  surely  could 
know  nothing  about  the  peculiarities  of  the  infantile  stomach, 
or  the  idiosyncrasies  of  the  undeveloped  nervous  system. 
Even  if  he  had  practiced  for  years  among  the  deaf  and  dumb 
he  would  be  sorely  puzzled  to  interpret  aright,  at  the  first  en- 
counter, the  disease  language  of  infancy. 

And  yet  to  one  who  has  carefully  studied  the  habits  and  char- 
acteristics of  infants,  the  absence  of  articular  speech  is  no  bar- 
rier usually  to  a  correct  diagnosis ;  and  the  careful  observer  can 
often  tell  at  a  glance  by  features,  attitude  or  behavior  all  that 
language  could  convey  of  the  seat  and  nature  of  the  ailment. 
In  some  respects  the  diagnostician  is  aided  by  the  dumbness 
of  his  patient.  If  there  is  no  speech,  so  also  there  is  no  pre- 
varication nor  dissimulation.  The  infant  does  not,  intention- 
ally or  otherwise,  place  undue  stress  on  trifling  symptoms 
which  might  conceal  or  obscure  a  real  and  serious  malady.  In 
pulmonary  complaints  the  absence  of  visible  sputa  is  not  a 
serious  loss,  for  other  signs  are  present  and  available  to  make  it 
easy  to  estimate  the  true  condition  of  affairs.  The  same  is 
true  of  the  urine.  Indeed,  I  fancy  that  with  the  exercise  of 
a  due  amount  of  patience,  the  skillful  physician  will  make 
fewer  mistakes  in  diagnosing  the  ills  of  infancy  than  in  an 
equal  number  of  those  maladies  more  commonly  met  with 
in  adults,  however  intelligent  and  voluble  they  may  be.  To 
point  out  and  elaborate  in  detail  all  of  the  differences  be- 
tween child-life  and  adult-life  would  require  a  volume  larger 
than  this  and  would  then  be  more  curious  and  interesting 
than  useful. 

There  is  scarcely  an  organ  or  a  tissue  that  behaves  precisely 
alike  in  the  two  epochs.  In  maturity  there  is,  until  old  age 
begins,  a  daily  balance  between  waste  and  repair.  There  is  no 
increase  in  growth,  or  material  change  in  organ  or  function. 
Childhood,  however,  is  a  period  of  rapid  change — of  growth 
and  development. 

Some  of  the  organs,  such  as  the  reproductive,  whose  offices 
are  to  cut  an  important  figure  later  on,  are  now  dormant  and 
inactive.  Others  having  done  important  work  during  embry- 
onic life  are  ceasing  their  activity  and  undergoing  a  more  or 
less  rapid  process  of  absorption — atrophy. 

Anatomical  Peculiarities  of  Infancy. — In  a  general 
way  it  may  be  said  that  at  birth  the  bones  are  more  elastic  and 
less  firm  ;  they  co'ntain  more  animal  and  less  earthy  matter 
than  in  advanced  years ;  they  are  more  cartilaginous,  and  their 
growth  is  more  from  cartilage  than  periosteum.  Certain  aber- 
rations of  ossification  are  now  noticeable  in  certain  cases  which 


ANATOMICAL  PECULIARITIES.  3 

may  destroy  the  symmetry  of  normal  growth  or  prejudice  the 
life  of  the  child.  The  skull,  which  is  intended  to  support  the 
brain  and  its  blood  vessels,  may  prevent  their  due  develop- 
ment, while  an  insufficient  degree  of  ossification  or  an  undue 
amount  of  sutural  substance  may  conduce  to  an  enlargement 
of  the  blood  vessels  and  consequent  effusion.  The  separate 
bones  of  the  skull  are  but  loosely  articulated  at  first,  but  at  a 
variable  period  the  sutures  are  ultimately  obliterated.  The 
yielding  nature  of  the  skull  at  this  time  is  such  that  it  may  be 
indented  by  a  blow,  or  compressed  by  a  bandage,  or  its  shape 
may  even  be  altered  by  the  weight  of  the  contained  brain,  if 
the  infant  is  allowed  to  lie  habitually  on  one  side. 

The  fontanels  are  two  irregular  but  somewhat  triangular 
openings  with  membranous  coverings  at  the  angles  of  the  pari- 
etal bones.  The  anterior  and  larger  one  of  the  two  fontanels 
is  situate  at  the  junction  of  the  parietal  and  frontal  bones,  or 
more  correctly  speaking,  at  the  junction  of  the  coronal  and 
sagital  sutures ;  the  posterior,  at  the  junction  of  the  parietal 
and  occipital  bones.  As  a  rule,  these  fontanels  are  larger  at  six 
months  of  age  than  they  are  at  birth,  the  reason  being  that  the 
growth  and  expansion  of  the  brain  within  the  calvaria  goes  on 
more  rapidly  than  the  process  of  ossification.  The  latter,  how- 
ever, soon  overtakes  the  former  and  both  fontanels  should  be 
closed  before  the  end  of  the  second  year.  They  are  often 
closed  much  earlier  than  this — as  soon,  indeed,  as  the  fifteenth 
or  sixteenth  month.  When  remaining  unclosed  into  the  third 
year,  the  fact  has  a  significance  that  will  appear  when  we  come 
to  speak  of  rickets. 

During  infancy  and  childhood  the  jaw  and  the  teeth  are  in 
a  rudimentary  state,  and  their  lack  of  development  makes  the 
facial  portion  of  the  skull  look  disproportionately  small.  The 
upper  and  lower  maxillary  bones  undergo  various  modifications 
until  both  the  temporary  and  permanent  teeth  are  completed, 
and  indeed  do  not  reach  their  fixed  and  ultimate  form  until  the 
age  of  puberty.  The  evolution  of  the  teeth  and  the  progress- 
ive stages  leading  thereto  will  be  treated  of  later  on  under  the 
head  of  teething. 

The  vertebral  column  is  straighter  and  the  insertion  of  the 
ribs  more  rectangular  at  their  insertion  at  the  transverse  pro- 
cesses of  the  vertebra  and  the  sternum.  This  renders  respira- 
tion more  abdominal  than  costal  and  the  viscera  of  the  abdom- 
inal cavity  appear  more  prominent. 

The  nervous  system  in  infancy  probably  shows  greater  differ- 
ences relatively  than  any  other  portion  of  the  anatomy.  The 
brain  at  birth  is  very  large.  Its  weight  is  one-sixth  of  the 
entire  weight  of  the  body,  while  in  the  adult  it  is  one-sixtieth. 


4  THE  DISEASES  OF  CHILDREN. 

The  brain  substance  is  soft  and  pasty  and  less  distinctly  sepa- 
rated into  medullary  and  cineritious  matter  ;  indeed,  its  gray 
and  white  substances  differ  but  little  in  color  and  composition. 
The  convolutions  are  less  prominent  and  less  numerous.  The 
nerves  of  special  sense  are  fully  developed,  but  are  inactive. 
The  nerves  of  organic  life — the  sympathetic — are  quite  pro- 
portionate to  age  and  development. 

The  spinal  cord,  like  the  brain,  has  not  yet  the  consistency  of 
a  later  period.  The  anterior  horns  are  unduly  prominent  and 
are  therefore  especially  sensitive  to  pathological  changes. 
The  peripheral  nerves  are  relatively  large,  but  lack  the  excita- 
bility they  have  later.  Toward  the  end  of  the  first  year,  how- 
ever, this  excitability  grows  rapidly  ;  much  more  so  than  that 
of  the  inhibitory  nerves.  During  the  first  month  of  extra- 
uterine life,  all  muscular  movements  are  not  controlled  by  will- 
power at  all,  but  are  purely  reflex.  After  this  time,  however, 
the  brain  develops  very  fast  indeed,  although  the  development 
is  by  no  means  uniform.  Certain  cerebral  functions  spring  into 
existence  one  after  another,  coincident  with  other  anatomical 
evolutions. 

The  lymphatic  system  is  remarkably  well  developed  in 
infancy,  comparatively  speaking.  So  also  is  the  glandular. 
The  liver  is  one  of  the  first  formed  organs  in  the  embryo  and 
at  the  fourth  week  of  embryonic  life  it  occupies  nearly  the  whole 
abdominal  cavity,  and  constitutes  one-half  the  entire  weight  of 
the  body.  From  this  time,  however,  it  diminishes  in  bulk 
until  birth,  when  it  occupies  nearly  the  upper  half  of  the  abdo- 
men, and  its  proportional  weight  to  that  of  the  body  is  as  one 
to  eighteen.  During  infancy  and  early  childhood  its  position 
is  such  that  its  lower  margin  can  be  felt  about  half  an  inch 
below  the  costal  cartilages.  In  the  middle  line  the  liver  is  in 
close  relation  to  the  skin  in  front  of  the  stomach  and  reaches 
about  half  way  between  the  ensiform  cartilage  and  the  umbil- 
icus. Here  its  lower  edge  corresponds  to  a  line  drawn  from 
the  ninth  right  to  the  eighth  left  costal  cartilage. 

The  thymus  gland  is  situated  just  behind  the  top  of  the 
sternum,  extending  when  fully  developed,  at  the  end  of  the 
second  year,  into  the  root  of  the  neck  over  the  trachea  and 
separated  from  the  great  vessels  by  the  thoracic  fascia.  It 
rests  below  upon  the  pericardium,  just  above  the  point  where 
the  pleura  approach  each  other.  After  the  second  year  it 
diminishes  until  it  entirely  disappears  or  is  substituted  by  a 
mass  of  fat.  It  is  of  a  pinkish  gray  color  and  lobulated,  and 
at  birth  weighs  half  an  ounce.  Its  disappearance  takes  place 
often  at  the  age  of  puberty  and  sometimes  not  until  after  mid- 
dle life  is  reached. — McLellan. 


PHTSIOLOGICAL  PECULIARITIES.  5 

The  stomach  in  infancy  presents  some  peculiarities  which 
are  worthy  of  mention.  The  most  noticeable  of  these  is  the 
vertical  position  which  it  occupies  in  the  abdomen.  In  the  new 
born  it  presents  more  the  appearance  of  a  simple  enlargement 
or  expansion  of  the  esophagus.  Its  fundus  is  wanting  and  it 
does  not  have  the  larger  and  smaller  curves.  The  valvular 
construction  of  the  cardiac  orifice  is  deficient  in  infants,  which 
accounts  for  the  facility  with  which  they  vomit  when  the  vis- 
cus  is  from  any  cause  over  distended. 

The  circulatory  system  of  the  newly  born,  except  during  the 
first  few  days,  shows  but  little  change  from  that  of  the  adult, 
except  that  the  veins  are  relatively  small  while  the  arteries  are 
relatively  large.  Shortly  before  birth  the  heart  loses  those 
peculiarities  which  distinguish  the  fetal  heart  and  the  organ 
rapidly  assumes  its  normal  condition  for  life.  The  changes 
which  take  place  in  the  circulation  of  the  blood  at  this  time 
are  remarkable.  The  umbilical  vein  and  the  ductus  venosus 
become  empty  and  contract  and  are  ultimately  converted  into 
the  fibrous  cords  which  become  the  round  ligament  of  the 
liver.  But,  as  Holden  says,  "  It  is  well  to  bear  in  mind  that 
these  important  vascular  changes  do  not  take  place  suddenly 
at  birth,  but  that  they  are  the  result  of  gradual  develop- 
ment which  is  completed  at  or  soon  after  birth,  mainly  by 
the  act  of  inspiration,  whereby  the  blood  passes  through 
the  lungs,  the  placental  circulation  at  the  same  time  being 
interrupted." 

Physiological  Peculiarities. — Comparing  infancy  with 
mature  age,  there  is  a  similar  difference  to  be  noted  in  the  phys- 
iology as  well  as  in  the  anatomy  of  the  organism.  To  be  sure, 
all  of  the  vegetative  functions,  those  which  are  essential  to  life, 
are  performed,  but  most  of  them  are  but  feebly  carried  on  and 
these  are  easily  disturbed  by  trifling  causes.  The  skin  of  the 
new  born,  when  cleansed  of  its  sebaceous  matter  and  its  vernix 
caseosa,  is  found  to  be  much  more  red  and  sensitive  than  in  later 
life,  and  during  the  first  few  weeks  after  birth  there  is  usually 
more  or  less  desquamation.  There  is  but  little  perspiration, 
but  the  sebaceous  glands  are  very  active,  especially  on  the  scalp. 
Unless  this  sebaceous  matter  is  constantly  cleansed  away,  in- 
fantile eczema  is  very  prone  to  result.  During  the  first  three 
or  four  months  there  is  no  secretion  of  tears.  The  new  born 
and  the  dying  do  not  weep.  After  the  first  three  or  four 
months,  the  absence  of  tears  is  not  a  good  sign.  It  has  been 
found  that  the  blood  of  infants  is  less  in  proportion  to  weight 
of  the  entire  body  than  in  adult  life ;  and  this  blood  has  "  less 
fibrin,  fewer  salts,  less  hemaglobulin,  less  soluble  albumen,  less 


6  THE  DISEASES  OF  CHILDREN. 

specific  gravity  and  more  white  corpuscles  than  the  blood  of 
advanced  age." 

The  pulse  of  infants  and  children  is  very  irritable  and  easily 
influenced  by  slight,  even  physiological,  causes.  It  is  also  very 
irregular  in  rhythm,  owing  to  the  variability  and  instability  of 
the  nerve  supply.  Indeed,  the  pulse  in  infancy  is  so  easily  per- 
turbed that  it  loses,  when  considered  alone  by  itself,  much  of 
its  usual  pathological  significance. 

The  normal  frequency  of  the  pulse  at  birth  is  140  and  during 
the  first  few  weeks  of  life  may  fluctuate  between  150  and  120, 
being  rather  more  frequent  in  females  and  in  smaller  infants. 
At  the  end  of  the  first  year  the  rate  varies  from  100  to  120. 
After  this  the  pulse  beats  about  100  and  gradually  becomes 
less  frequent  until  at  five  years  the  normal  frequency  is  gener- 
ally about  90. 

The  respiratory  function  is  subject  to  the  same  variableness 
as  the  pulse.  During  the  first  few  months  it  is  no  uncommon 
thing  to  find  a  veritable  Cheyne-Stokes  rhythm,  which  is  either 
normal  or  occasioned  by  causes  so  trivial  as  scarcely  to  be  con- 
sidered as  pathological.  At  birth  the  number  of  respirations 
per  minute  varies  from  30  to  50,  the  mean  between  these  figures 
being  the  average.  They  are  fewer  during  sleep  and  are  then 
also  more  regular.  During  the  first  year  of  life  the  respirations 
range  between  25  and  35,  but  these  figures  are  increased  by 
crying  or  laughing  and  diminished  by  fixing  the  infant's  at- 
tention. Von  Pettenkofer  has  estimated  that  a  child  produces 
in  proportion  to  its  body-weight  nearly  three  times  as  much 
carbonic  acid  as  an  adult. 

Temperature. — The  clinical  thermometer  is  of  the  greatest 
value  in  the  treament  of  the  diseases  of  infancy  and  cannot 
safely  be  dispensed  with.  The  feeling  of  the  skin  is  very  decep- 
tive. The  hand  may  detect  no  fever  at  all  when  the  internal  tem- 
perature may  be  raised  several  degrees  above  the  normal.  It 
is  one  of  the  peculiarities  of  infancy  that  very  slight  and  tran- 
sient causes  produce  a  sudden  elevation  of  the  temperature,  al- 
though, as  a  rule,  in  a  healthy  child  the  thermometer  shows  a 
fairly  constant  mean  of  99°  in  the  rectum.  It  rises  a  half-degree 
or  so  after  a  hearty  meal,  but  there  is  no  marked  difference  in 
health  between  the  morning  and  evening. 

On  account  of  the  excitability  of  the  nervous  system  which 
has  already  been  referred  to,  children  are  \^xy  subject  to  what 
may  be  called  "  irritative  fever,"  i.  e.,  a  form  of  pyrexia  which 
results  from  any  trifling  cause  that  frets  or  worries  it. 

Dentition  is  a  frequent  promoter  of  this  form  of  febrile  ex- 
citement and  so  is  irritation  of  the  bowels  by  scybala.  food 


GROWTH.  7 

injested  that  does  not  quite  agree  and  intestinal  worms.  This 
irritative  fever  of  which  we  are  speaking  is  always  marked  with 
great  irregularity.  There  is  no  regular  evening  exacerbation  or 
morning  remission  as  in  most  other  forms  of  pyrexia. 

Sometimes,  instead  of  an  elevation,  the  thermometer  shows  a 
marked  lowering  of  the  temperature.  This  is  usually  a  sign 
of  malnutrition.  Anything  which  exhausts  the  system,  like 
chronic  vomiting  or  purging,  is  likely  to  be  followed  by  a  fall  in 
temperature.  In  convalescence  from  acute  diseases,  the  tem- 
perature may  remain  for  days  or  even  weeks  at  a  lower  level 
than  that  of  health.  Dr.  Eustace  Smith  has  observed  that  chil- 
dren who  are  growing  rapidly  are  subject  to  a  nightly  rise  in  tem- 
perature, the  thermometer  sometimes  ranging  as  high  as  ioo°  or 
ioo.6°.  Under  these  circumstances,  this  phenomenon  is  physio- 
logical and  not  pathological  in  its  nature.  In  infants  the  tem- 
perature should  always  be  taken  in  the  rectum.  Here  the 
thermometer  can  always  be  used  safely  and  an  accurate  registry 
secured.     This  cannot  be  said  of  the  axilla  or  the  groin. 

Growth. — The  average  weight  of  a  healthy  infant  at  birth 
is  seven  pounds,  the  female  being  somewhat  less  heavy.  This 
weight  is  about  doubled  at  five  months,  and  trebled  at  the 
end  of  the  first  year  of  life. 

The  average  length  of  a  child  at  birth  is  19*5  inches,  and  the 
subjoined  table  of  the  monthly  rate  of  increase  is  given  by 
Louis  Starr. 

Birth 19  •  5  inches 

1  month 20  ■  5  " 

2  months 21  " 

3  months 22  " 

4  months 23  " 

5  months 23 '  5  " 

6  months 24  " 

7  months 245  " 

8  months 25  " 

9  months 25*5  " 

10  months 26  " 

1 1  months 26 '  5       " 

12  months 27  " 

"  During  the  second  year  the  increase  is  from  three  to  five 
inches  ;  in  the  third  from  two  to  three  and  a  half  inches  ;  in 
the  fourth  from  two  to  three  inches." 

The  gain  in  weight  per  annum  for  the  first  few  years  averages 
four  or  five  pounds. 

For  five  years  and  onwards  the  figures  both  for  height  and 
weight  have  been  worked  out  by  Dr.  G.  W.  Stephenson,  whose 
table  is  subjoined. 


THE  DISEASES  OF  CHILDREN. 


AVERAGES    OF    HEIGHT    AND    WEIGHT    OF    BOYS    AND    GIRLS   OF   ENGLISH 

SPEAKING    RACES,  CALCULATED    FROM    THE    TOTAL    OF 

BRITISH    AND    AMERICAN    STATISTICS. 


Boys. 


Girls. 


-^ 

r" 

^ 

Height    in 

Weight  in 

Age. 

Height    in 

Weight  in 

Age. 

inches. 

pounds. 

inches. 

pounds. 

5 

41    30 

40  49 

s 

41  OS 

39  63 

6 

43-88 

44  79 

6 

42-99 

42  84 

7 

45  86 

49  39 

7 

44-98 

47  08 

8 

47  41 

54  41 

8 

47-09 

52  12 

9 

4969 

59-82 

9 

49  05 

56-28 

10 

51  76 

66 -40 

10 

51  19 

6217 

II 

53  47 

71-09 

II 

53  26 

68-47 

12 

55  OS 

76-81 

12 

55 '77 

77  35 

13 

5706 

83-72 

13 

5796 

87-82 

H 

5960 

93  46 

14 

59-87 

97  56 

IS 

62  27 

104-90 

15 

61  01 

105  44 

i6 

64  66 

12000 

16 

61  "67 

112  36 

17 

66  20 

12919 

17 

62  22 

11521 

18 

66  81 

13497 

18 

62  19 

116-43 

Dr.  H.  Parker,  Resident  Physician  of  the  New  York  Infant 
Asylum,  weighed  immediately  after  birth  170  infants — 89  males 
and  81  females — born  consecutively  and  at  term,  with  the 
following  result  : 

Average  male  weight 7  lbs.  11  oz. 

Average  female  weight 7  lbs.     4  oz. 

Fifty  of  these  who  were  wet-nursed  and  apparently  well 
taken  care  of,  were  weighed  when  one  week  old,  with  the 
following  result : 

Increase  of  weight  in 32  cases 

Loss  of  weight  in 13  cases 

Average  gain \^^  oz. 

Average  loss 2>)4,  oz. 

Greatest  gain 12       oz. 

Greatest  loss 6      oz. 

AVERAGE    GAIN. 

From  birth  to  age  of  four  months  (25  cases).  .4  lbs.  8^     oz. 

From  3  to  6  months  (6  cases) 3  lbs.  3^       oz. 

From  6  to  9  months  (6  cases) 2  lbs.  7^       oz. 

From  9  to  12  months  (6  cases) i  lbs.  15)^  oz. 

This  would  indicate  that  American-born  babies  were  some- 
what heavier  than  the  average  of  English-speaking  races, 
according  to  Stephenson's  tables. 


PATHOLOGICAL  PECULIARITIES.  9 

Pathological  Peculiarities.— Most  of  the  observations 
and  deductions  that  would  properly  come  under  this  head  will 
be  spoken  of  when  the  diseases  are  described  which  would  illus- 
trate them.  A  few  of  these  peculiarities,  however,  may  be 
mentioned  here,  since  they  are  of  a  general  nature  and  are  more 
incidental  to  the  time  of  life  than  to  any  peculiarity  of  the  dis- 
ease itself.  The  peculiarities  referred  to  often  invest  the  com- 
monest forms  of  illness  with  strange  features  which  may  be  a 
source  of  obscurity  and  confusion.  A  functional  derangement 
which  in  the  adult  would  give  rise  only  to  slight  local  symptoms, 
may  in  the  child  be  accompanied  by  signs  of  some  general  dis- 
tress and  the  presence  of  local  suffering  may  be  thus  over- 
shadowed or  completely  concealed. 

The  swallowing  of  a  small  portion  of  indigestible  food  may 
throw  the  child  into  a  burning  fever,  with  intense  agitation  and 
restlessness,  or  it  may  cause  convulsions  or  stupor  from  which 
it  can  with  difificulty  be  aroused.  I  once  knew  a  child  of  my 
friend  Dr.  S.  P.  Hedges,  of  this  city — a  child  some  two  years 
old — to  have  convulsions  at  frequent  intervals  all  one  day  from 
eating  some  partially  cooked  mashed  potatoes.  As  soon  as  the 
offending  substance  was  expelled  from  the  system  the  convul- 
sions ceased  and  the  child  resumed  its  play  as  well  as  ever. 
Indeed,  it  may  be  stated  that  an  eclamptic  attack  in  a  child  is 
a  symptom  which,  in  the  majority  of  cases,  has  far  less  signifi- 
cance than  a  similar  attack  would  have  in  an  adult.  In  the 
latter  it  is  usually  the  evidence  of  some  serious  cerebral  lesion 
and  its  occurrence  excites  quite  naturally  the  greatest  alarm. 
In  the  child,  however,  a  "  fit"  is  commonly  the  evidence  only 
of  some  disturbance  in  the  nervous  system,  the  amount  of  act- 
ual disturbance  and  the  symptoms  being  very  disproportionate. 
It  may  be  only  a  trifling  irritant  of  the  most  transient  nature, 
and  of  no  gravity  whatever.  In  the  beginning  of  acute  illnesses, 
such  as  the  eruptive  fevers,  we  often  have  spasms  at  the  outset, 
taking  the  place  of  the  rigor  so  common  a  symptom  in  the  begin- 
ning of  febrile  disease  in  the  adult.  It  is  not  to  be  understood, 
however,  that  convulsions  in  the  child  are  always  of  this  inno- 
cent character.  They  may  and  do  occur  as  a  consequence  of 
cerebral  disease,  but  in  such  cases  are  frequently  repeated  or 
are  prolonged  and  are  succeeded  by  coma,  rigidity,  paralysis  or 
other  signs  of  centric  irritation.  Vomiting,  which  in  the  adult  is 
often  indicative  of  grave  gastric  or  other  organic  disease,  is  in 
children  a  symptom  of  the  most  trifling  import  usually,  and 
means  or  may  mean  only  an  overloaded  stomach.  "As  pro- 
found a  disturbance  may  be  excited  by  the  simplest  functional 
derangement  as  by  the  severest  organic  malady,  so  that,  to  the 
eye  accustomed  to  the  orderly  progress  of  disease  in  the  adult> 


10  THE  DISEASES  OF  CHILDREN. 

symptoms  seem  to  have  lost  their  value  and  to  be  calculated 
rather  to  mislead  than  to  inform." 

Children  sometimes  suffer  the  most  violent  nocturnal  delir- 
ium— the  so-called  "  night  terrors  " — from  slight  derangement 
of  the  stomach  from  worms  or  otherwise. 

Another  peculiarity  of  infants  is  the  fact  that  they  quickly 
part  with  their  heat  and  are  easily  chilled.  They  are  therefore 
especially  prone  to  catarrhal  affections,  which  may  seriously 
interfere  with  the  functions  of  the  organ  involved,  and  this  ar- 
rest of  function  may  of  itself  lead  to  fatal  results  ;  and  a  child 
may  die  with  tissues  sound,  organs  healthy  and  no  morbid  ap- 
pearances left  to  declare  the  nature  of  the  complaint.  Post- 
mortem examinations  have  been  made  of  children  dead  from 
marasmus,  in  whom  not  the  slightest  trace  of  organic  disease 
has  been  discoverable. 

The  gravity  of  certain,  indeed  it  may  be  said  of  all,  diseases 
is  modified  either  one  way  or  another  by  age.  Typhoid  fever, 
measles,  and  perhaps  croupous  pneumonia  generally  run  a 
milder  course  in  earlier  than  they  do  in  later  life ;  but  others, 
such  as  acute  affections  of  the  gastro-intestinal  tract,  are  far  the 
more  severe  in  comparison  with  the  youth  of  the  patient.  The 
infant  is  so  dependent  upon  a  frequent  supply  of  nourishment, 
that  any  abrupt  interference  with  the  nutritive  processes  is  an 
event  of  the  utmost  gravity.  It  is  often  followed  by  so  much 
exhaustion  that  the  infant  rapidly  sinks  and  dies.  It  is  this 
sudden  and  complete  cutting  off  of  the  nutritive  supply  which 
constitutes  the  chief  danger  of  acute  disease,  and  all  through 
early  life  illness  is  often  serious  in  exact  proportion  to  the 
degree  in  which  the  alimentary  canal  participates  in  the  de- 
rangement. When  children  retain  their  ability  to  eat  and 
digest,  while  passing  through  an  acute  illness,  their  recovery'  is 
generally  assured  and  their  convalescence  rapid.  In  uncom- 
plicated cases  the  strength  appears  to  be  recovered  almost  as 
quickly  as  it  was  lost.  When,  in  such  cases,  convalescence  is 
delayed  it  is  almost  invariably  due  to  a  complication,  a 
thing  which  is  far  from  being  uncommon. 

From  chronic  maladies  convalescence  is  usually  slow,  the 
delay  being  no  doubt  partly  due  to  the  fact  that  this  class  of 
diseases  is  more  common  in  children  of  a  scrofulous  habit  and 
the  strumous  cachexia,  as  is  well  known,  is  in  itself  a  barrier  to 
rapid  improvement.  Another  reason  for  this  tardiness  in  re- 
covery is  found  in  the  fact  that  in  children  chronic  ailments 
nearly  always,  in  the  course  of  their  progress,  sooner  or  later 
affect  the  alimentary  canal  and  such  complaints  are  invaria- 
bly slow. 

When  sudden  death  occurs  to  a  child  previously  healthy,  or 


SIGNS  OF  DISEASE.  11 

at  least  to  all  appearances  so,  it  is  usually  due  to  laryngismus, 
to  syncope,  or  to  collapse  of  the  lung.  Occasionally,  although 
not  frequently,  it  is  a  consequence  of  convulsions.  Pulmonary 
collapse  is  frequently  met  with  in  infants  or  children  who  have 
been  greatly  enfeebled  by  some  wasting  disease.  A  fatal  ter- 
mination of  disease  is  usually  marked  by  a  sudden  alteration  of 
the  temperature,  either  dropping  below  the  normal  or  rising 
quickly  to  io8°  or  109°.  The  former  is  more  apt  to  be  the 
case  in  chronic  diseases  or  in  collapse  of  the  lung,  the  latter  in 
cerebral  cases  or  gastro-intestinal  derangements. 

Signs  of  Disease. — "  The  clear,  fresh  complexion  of  a 
healthy  baby  or  a  young  child  is  familiar  to  everyone.  A  loss 
of  its  purity  and  clearness  is  one  of  the  first  indications  of 
digestive  derangement.  The  face  becomes  muddy-looking 
and  the  upper  lip  whitish  or  bluish.  Blueness  of  the  upper  lip 
in  early  life  is  a  common  sign  of  labored  digestion.  In  some 
children  difficult  digestion  is  shown  by  an  earthy  tint  of  the 
face  which  spreads  to  the  forehead.  It  appears  a  short  time 
after  the  meal  and  may  last  several  hours.  In  chronic  bowel 
complaints  the  earthy  tint  is  constant.  It  is  common  in  cases 
of  chronic  diarrhea  in  the  infant,  and  if  at  the  same  time  there 
is  much  emaciation,  the  derangement  is  likely  to  prove 
obstinate.  In  syphilis  the  prominent  parts  of  the  face — the 
nose,  cheeks,  chin  and  forehead — assume  a  swarthy  hue.  In 
lardaceous  disease  the  complexion  is  peculiarly  pallid  and 
bloodless  ;  in  rickety  children  whose  spleens  are  greatly  en- 
larged it  has  a  greenish  or  faint  olive  cast ;  and  in  cyanosis  the 
face  has  a  characteristic  leaden  tint,  the  conjunctiva  are  con- 
gested, and  the  eyelids  and  lips  thick  and  purple.  Lividity  of 
the  skin  around  the  mouth  and  nose  with  a  purple  tint  of  the 
eyelids  is  common  as  a  result  of  deficient  aeration  of  the  blood. 
In  severe  cases  the  cheeks  at  the  same  time  have  a  dull  white 
color,  and  the  symptom  is  an  unfavorable  one.  In  the  spas- 
modic stage  of  whooping-cough  the  face  looks  swollen  as  well 
as  livid,  the  lips  and  eyelids  are  purple  and  thick,  and  the  con- 
junctiva are  congested  and  often  bloodshot. 

"  In  addition  to  the  actual  tint  of  the  face,  the  general  expres- 
sion must  receive  attention.  In  a  healthy  babe  the  physiog- 
nomy denotes  merely  sleepy  content,  and  no  lines  mark  the 
smooth,  uniform  surface.  Pain  is  indicated  by  a  contraction  of 
the  brows  which  wrinkles  the  skin  of  the  forehead.  This  is 
especially  noticeable  if  the  head  is  the  seat  of  suffering.  If 
the  pain  be  in  the  abdomen,  the  nose  often  looks  sharp,  the 
nostrils  are  dilated,  and  the  child  draws  up  the  corners  of  the 
mouth  with  a  peculiar  expression  of  distress.     In  every  case  of 


12  THE  DISEASES  OF  CHILDREN. 

serious  disease  the  face,  even  in  repose,  has  a  haggard  look, 
which  must  not  be  disregarded.  If  this  be  accompanied  by  a 
hollowness  of  the  cheeks  and  eyes  the  result  is  a  ghastly  ex- 
pression which  cannot  escape  attention  ;  but  a  distressed  look 
may  be  seen  in  the  face,  although  there  is  no  loss  of  roundness 
of  feature.  If  this  be  the  case,  even  in  the  absence  of  striking 
symptoms,  we  may  confidently  predict  the  onset  of  serious 
disease. 

"  Often  an  inspection  of  the  face  will  help  us  to  a  knowledge 
of  'the  part  of  the  body  affected.  Many  years  ago  M.  Jadelot 
pointed  out  certain  lines  or  furrows  in  the  face  of  an  ailing 
infant  which  by  their  position  indicate  the  seat  of  the  derange- 
ment, thus : 

"  The  occulo-zygomatic  line  begins  at  the  inner  canthus  of  the 
eye,  passes  thence  downwards  and  outwards  beneath  the  lower 
lid  and  is  lost  on  the  cheek  a  little  below  the  projection  of  the 
malar  bone.  This  line  points  to  disease  or  derangement  of  the 
brain  and  nervous  system. 

"The  nasal  line  rises  at  the  upper  part  of  the  ala  of  the  nose 
and  passes  downwards,  curling  round  the  corner  of  the  mouth. 
This  line  is  a  constant  feature  of  abdominal  mischief,  and  is 
never  absent  in  cases  of  gastro-intestinal  derangement. 

"  The  labial  line  begins  at  the  angle  of  the  mouth  and  runs 
outward  to  be  lost  in  the  lower  part  of  the  face.  This  is  more 
shallow  than  the  preceding.  It  is  a  fairly  trustworthy  sign  of 
disease  in  the  lungs  and  air-passages. 

"  These  lines  have  a  distinct  practical  value  and  should  be 
always  attended  to." — Eustace  Smith. 

The  attitude  of  the  child  as  he  lies  in  his  cot  is  not  to  be 
overlooked.  It  is  sometimes  very  significant.  Healthy  infants 
and  children  sleep  perfectly  quietly.  Frequent  turning  of  the 
body,  twitching  of  the  muscles,  jumping  and  starting,  always 
indicate  some  derangement  somewhere.  It  may  indicate 
merely  feverishness  or  digestive  derangement,  but  it  is  a  depar- 
ture from  perfect  health.  If  the  head  is  moved  constantly 
from  side  to  side  on  the  pillow  it  is  probably  annoyed  with 
pain  in  the  head  or  ear.  When  the  hand  is  frequently  car- 
ried to  the  forehead  or  side  of  the  head  it  usually  means  the 
same  thing. 

Some  writers  attach  much  importance  to  the  cry  of  the  child 
and  seem  to  regard  its  character  as  having  much  significance. 
There  is  to  their  minds  a  hungry  and  a  thirsty  cry,  a  ci  y  indica- 
tive of  colic  and  another  peculiar  to  earache.  I  must  confess 
that  I  find  in  these  cases  that  the  cry  is  generally  supplemented 
by  other  movements  of  the  body,  that  to  me  are  more  signifi- 
cant than  the  cry  itself.     But  these  movements  must  be  studied 


EXAMINATION  OF  SICK  CHILDREN.  13 

at  the  bedside  and  each  for  himself.  They  are  indescribable  by 
words.     The  absence  of  crying  is  a  serious  omen. 

All  healthy  children  cry  whenever  anything  causes  pain  or 
discomfort.  When  it  does  not  do  so,  it  betokens  or  may  be- 
token serious  disease.  There  is  one  cry,  however,  that  is  so  pe- 
culiar and  so  significant  that  it  deserves  special  mention.  It  is 
the  "  cri  excephalique  "  of  the  French.  It  is  sharp,  shrill  and 
solitary  and  is  distinctive  of  cerebral  disease. 

It  is  very  different,  the  very  antipodes  of  the  long-drawn 
moans  and  wails  of  marasmus  and  tubercular  peritonitis. 

Examination  of  Sick  Children. — Nearly  every  work  upon 
diseases  of  children  contains  several  pages  of  more  or  less  ex- 
plicit directions  as  tohowthestudent  or  the  young  practitioner 
is  to  go  to  work  to  examine  a  child  who  is  supposed  to  be  ill,  in 
order  that  he  may  ascertain  the  seat  and  nature  of  the  com- 
plaint and  be  able  to  prescribe  intelligently  therefor. 

1  see  but  little  reason  for  this.  The  printed  page  can  never 
teach  the  novice  to  be  an  expert.  The  medical  practitioner 
who  essays  to  treat  successfully  the  diseases  of  infancy  must 
have  great  patience  and  greater  tact.  Both  of  these  accom- 
plishments may  be  cultivated,  but  they  cannot  be  taught. 
Their  possession  is  a  gift  rather  than  an  acquirement,  and  all 
the  written  directions  in  the  world  cannot  teach  that  which  is 
inherently  wanting.  To  illustrate,  I  find  this  in  a  volume  be- 
fore me :  "  To  examine  the  abdominal  organs  at  all  satisfactor- 
ily, the  child  must  lie  on  his  back  with  his  head  and  shoulders 
raised  by  a  pillow.  The  mother  or  nurse  should  sit  upon  the 
bed  by  his  side  and  the  practitioner  should  take  care  that  the 
hand  he  applies  to  the  belly  is  warm  and  does  not  press  too 
abruptly,  so  as  to  give  pain.  This  part  of  the  examination  is 
usually  submitted  to  without  opposition  if  the  child  be  hu- 
mored and  cheerfully  talked  to,  etc." 

This  is  all  well  and  good,  but  why  waste  words  and  time  try- 
ing to  teach  a  man  to  warm  his  hands  before  putting  them  on 
the  abdomen  of  a  sick  child,  or  try  to  teach  him  to  talk  good 
humoredly  or  cheerfully  to  a  child  that  is  howling  with  pain  ? 

This  cannot  be  taught  by  books.  To  attempt  to  do  so  is  to 
dally  with  failure.  The  place  to  learn  how  to  handle  a  sick 
child  is  in  the  medical  clinic  or  in  the  nursery,  where  practical 
experience  is  to  be  had.  Practice  is  better  than  precept.  What 
the  doctor  needs  in  the  chamber  of  a  sick  babe  is  the  same  kind 
of  common  sense  that  he  needs  and  must  have  to  be  a  welcome 
visitor  in  any  sick  room,  be  it  that  of  man,  woman  or  child. 
Hard,  practical,  common  sense  mingled  with  plenty  of  sympa- 
thy and  good  nature  are  the  essential  requisites  of  success. 


14  THE  DISEASES  OF  CHILDREN. 

No  rigid  rules  can  be  laid  down  for  the  guidance  of  the  exam- 
iner in  a  given  case.  The  history  of  the  ailment  and  the  general 
history  of  the  child  should  be  obtained  when  possible  from  the 
mother  or  the  nurse  in  charge. 

This  history  is  oftentimes  of  the  greatest  importance.  It 
sheds  light  or  may  help  to  decide  the  question  of  latent  ten- 
dencies, or  hereditary  taint.  It  should  serve  to  answer  the 
question  as  to  how  the  child  has  behaved  in  previous  illnesses ; 
of  their  nature  and  duration.  Mothers,  as  a  rule,  are  careful 
observers,  and  their  testimony  should  never  be  ignored.  In 
trifling  ailments  it  is  usually  not  necessary  to  unclothe  the  child, 
nor  subject  it  to  prolonged  and  wearisome  examination.  But 
except  in  acute  illnesses  where  the  symptoms  manifestly  do  not 
call  for  it,  this  is  necessary.  In  all  chronic  complaints  the  child 
should  be  stripped  to  the  skin,  so  that  a  thorough  inspection 
can  be  made  of  the  entire  body.  If  the  child  is  asleep  at  the 
time  of  the  visit,  so  much  the  better.  Certain  points  can  be 
covered  in  the  examination  better  than  afterwards.  For  in- 
stance, the  attitude  ;  the  posture,  if  easy  and  natural,  or  other- 
wise; the  color  of  the  face,  if  flushed  or  pale;  the  color  of  the 
lips,  if  white  or  livid  ;  the  state  of  the  skin,  whether  moist  or 
dry  ;  the  expression,  if  natural  or  painful.  We  should  note  the 
presence  or  absence  of  moaning,  starting,  twitching,  grinding  of 
the  teeth ;  the  action  of  the  nostrils,  if  quiet  or  working 
strongly  ;  the  eyes,  if  closed,  or  only  partly  closed,  or  staring ; 
the  respiration,  whether  abdominal  or  thoracic.  The  respira- 
tions may  now  be  counted,  as  well  as  the  pulse.  The  condition 
of  the  fontanels  should  be  noted  ;  if  closed  or  open,  if  pulsat- 
ing, expanded  or  depressed.  What  is  the  relative  size  and 
shape  of  the  head?  Are  the  veins  full  and  prominent?  How 
long  has  the  child  been  sleeping?  A  healthy  child,  under  three 
months  of  age,  should  sleep  twenty  hours  out  of  the  twenty- 
four.  During  the  next  six  months  it  should  average  from  fif- 
teen to  eighteen  hours.  All  of  these  matters  can  be  looked  aft- 
er before  the  sleeping  child  is  aroused,  when  the  examination 
must  proceed  in  a  very  different  manner,  and  when,  in  many 
cases,  all  the  tact  and  skill  and  patience  and  persistence  of  a 
major-general  of  infantry  will  necessarily  be  called  into  play. 
It  is  now  that  didactic  teaching  is  worthless.  When  ill,  the 
best-natured  of  babies  is  restless,  fretful,  irritable,  and  willful. 
It  will  not  bear  coercion.  It  resents  a  strange  presence.  It 
cannot  understand  the  reason  of  being  thumped  and  poked 
and  handled  in  strange  ways.  Observations  must  be  made  be- 
tween cries  ;  and  a  glance  must  suffice  for  prolonged  inspection. 
In  many,  indeed,  perhaps  in  most  cases,  a  little  adroit  cajolery 
will  place  the  doctor  upon  such  a  footing  of  familiarity,  that 


A  use  UL  TA  TION.  15 

all  needed  information  can  be  in  time  secured.  But  only  by 
patient  and  practiced  effort.  The  special  significance  of  the 
points  above  referred  to,  and  which  are  to  be  elicited  in  the  ex- 
amination, will  be  fully  brought  out  as  the  book  progresses. 
To  speak  of  them  now  would  only  amount  to  iteration.  Their 
meaning  will  be  be  best  understood  as  symptoms  of  the  mala- 
dies to  which  they  are  the  usual  accompaniments. 

Dr.  Louis  Starr,  in  his  admirable  work  on  the  "  Diseases  of 
the  Digestive  Organs  in  Children,"  has  given  such  succinct  di- 
rections for  examining  the  chest,  that  we  quote  the  following 
paragraphs: 

Aiiscultation. — "With  infants,  the  back  of  the  chest  is  most 
conveniently  auscultated  when  the  child  is  held  in  the  nurse's 
left  arm,  with  his  breast  against  hers,  his  chin  resting  upon  her 
left  shoulder,  his  left  arm  around  her  neck,  and  his  head  kept 
in  position  by  her  disengaged  hand.  The  front,  when  reclining 
on  the  back  on  a  pillow.  The  sides,  when  sitting  upright  on 
the  lap,  first  one  arm  and  then  the  other  arm  being  lifted  up  to 
allow  the  observer's  ear  to  be  applied.  Older  children  may  be 
made  to  take  the  same  positions  as  adults. 

"  It  is  not  sufficient  to  auscult  the  posterior  aspect  of  the 
thorax  alone,  as  is  stated  by  some  authors.  The  whole  chest 
should  be  examined,  particularly- in  doubtful  cases.  The  signs 
of  croupous  pneumonia  are  most  frequently  discoverable  at  one 
or  other  base  posteriorly ;  the  friction  sound  of  pleuritis  at  the 
junction  of  the  middle  and  lower  third,  laterally  ;  and  the  signs 
of  emphysema  at  the  apices  anteriorly.  Therefore,  unless  the 
exploration  be  thorough,  important  lesions  may  be  overlooked. 

"  In  healthy  infants  the  inspiratory  act  in  ordinary  breathing 
is  superficial,  and  the  respiratory  murmur,  as  a  consequence, 
feeble.  If,  however,  a  deep  inspiration  be  taken,  a  frequent 
occurrence  under  excitement  and  during  crying,  the  murmur 
becomes  loud,  or  assumes  the  character  that  Laennec  termed 
puerile  breathing.  After  the  age  of  two  years  this  form  of  res- 
piration is  habitual. 

"  Puerile  breathing  is  characterized  by  its  intensity,  a  prop- 
erty depending  upon  the  thinness  and  elasticity  of  the  chest- 
walls  in  childhood.  There  is  no  alteration  in  rhythm,  the  inspir- 
atory  element  of  the  murmur  being  directly  followed  by  the 
expiratory,  and  this  in  turn  by  an  interval  of  silence ;  neither  is 
there  any  change  in  the  pitch  or  duration  of  the  expiratory 
sound,  which  remains  lower  and  shorter  than  that  of  inspira- 
tion. In  other  words,  puerile  respiration  is  simply  a  very  in- 
tense vesicular  respiration.  The  normal  respiratory  murmur 
is  then  feebler  in  infants,  and  louder  in  children  over  two  years 
old,  than  in  adults. 


16  THE  DISEASES  OF  CHILDREN. 

"  The  breathing  is  louder  over  the  anterior,  lateral  and  poste- 
rior inferior  regions  of  the  thorax.  Faintest  over  the  scapular 
and  the  precordial  area.  This  absence  occurs  most  frequently 
in  young  children,  and  is  most  noticeable  over  the  lower  pos- 
terior portions  of  the  lungs.  In  the  interscapular  region,  the 
ear,  being  directly  over  the  larger  bronchi,  readily  detects  a  de- 
viation from  the  vesicular  quality.  Here  the  inspiratory  mur- 
mur is  loud,  harsh  and  somewhat  tubular  in  character.  There 
is  a  slight  pause  between  it  and  the  expiratory  murmur,  and 
the  latter  is  longer  in  duration  and  higher  in  pitch.  There  is, 
in  fact,  an  approach  to  the  bronchial  type  of  breathing,  which 
may  always  be  heard  in  its  purity  by  listening  over  the  trachea. 

"  Sometimes  a  difference  in  the  breathing  can  be  detected 
over  the  apices  anteriorly.  On  the  left  side  the  vesicular  quality 
is  purer,  on  the  right  the  intensity  is  greater.  The  difference 
is  most  decided  in  the  expiratory  element,  which,  also,  may  be 
slightly  prolonged  on  the  right  when  compared  with  the  left 
side.  These  modifications  are  due  principally  to  the  larger  size 
and  more  horizontal  course  of  the  right  primary  bronchus. 
They  are  perfectly  compatible  with  a  normal  state  of  the  lungs. 
Should,  however,  the  condition  at  the  apices  be  reversed,  and 
the  intensity  and  prolongation  of  the  expiratory  sound  be 
greater  on  the  left  side,  the  commencement  of  phthisis  is  indi- 
cated. 

"If  the  child  speaks,  cries  or  coughs  while  the  ear  is  applied 
to  the  chest  a  muffled,  rumbling  sound,  the  normal  vocal  reso- 
nance, will  be  heard.  At  the  same  time,  vibration  of  the  walls, 
the  vocal  fremitus,  can  be  felt. 

"  The  cardiac  sounds  are  readily  heard  when  the  ear  is  placed 
on  the  precordia.  In  young  infants  the  examination  is  some- 
what difficult,  on  account  of  the  rapid  and  excitable  action  of 
the  heart,  but  after  the  first  year,  the  circulation  becoming 
slower  and  more  regular,  there  is  little  trouble  in  distinguish- 
ing the  sounds,  and  even  slight  alterations  produced  in  them  by 
disease.  The  first  sound  is  longer  and  graver  than  the  second, 
and  the  rhythm  is  ordinarily  quite  regular.  In  health  the  sounds 
may  be  heard  under  both  clavicles  for  a  short  distance  to  the 
right  of  the  sternum,  and  sometimes  over  the  whole  anterior 
surface  of  the  chest.  After  muscular  effort  or  during  agitation, 
the  heart  sounds  may  be  audible  over  the  posterior  aspect  of 
the  chest,  but  they  are  more  distinct  in  this  position  when  the 
lower  lobe  of  either  lung  is  consolidated  by  pneumonic  exuda- 
tion. The  latter  point  is  often  of  great  value  in  distinguishing 
doubtful  cases  of  pneumonia  from  pleural  effusion. 

Palpation. — "  In  practicing  palpation  the  palmer  surface  of 
the  well-warmed    hand  must  be  applied  to  the  naked  chest. 


PERCUSSION.  17 

This  method  of  exploration  is  useful  as  a  means  of  determining 
the  number  of  respiratory  movements,  the  degree  of  expansion 
of  the  thoracic  walls,  the  position  of  the  cardiac  apex  beat,  the 
presence  or  absence  of  painful  regions  and  of  pleural  or  bron- 
chial fremitus,  the  existence  of  fluctuation  in  the  intercostal 
spaces  and  the  character  of  the  vocal  fremitus.  For  the  last 
purpose,  though,  it  is  hardly  worth  while  to  make  a  separate 
step  in  the  examination,  for  the  vocal  vibrations  can  be  readily 
distinguished  by  the  ear  when  applied  to  the  chest  in  auscul- 
tation. 

Percussion. — "  In  percussing  the  different  surfaces  of  the 
chest,  the  child  must  be  placed  in  the  same  position  as  for  aus- 
cultation. When  contrasting  the  two  sides,  percussion  should 
be  made  in  the  identical  regions,  and  during  the  same  period 
of  the  respiratory  movement.  Babies,  when  constrained  or  when 
disturbed,  hold  their  breaths  in  the  intervals  of  crying,  and  as 
they  always  do  so  at  the  end  of  an  inspiration,  this  is  a  favor- 
able time  to  seize  for  the  comparative  examination.  The  per- 
cussion strokes  must  be  lighter  than  in  the  adult,  but  in  other 
respects  the  operation  in  no  wise  differs. 

"  In  health  the  resonance  will  be  found  to  correspond  closely 
with  the  respiratory  murmur.  Thus,  in  infants  under  one  year, 
the  respiratory  murmur  being  feeble,  percussion  is  rather  in- 
sonorous.  Even  at  this  age  the  case  is  different,  when  a  deep 
breath  is  taken,  and  so  soon  as  puerile  respiration  becomes  es- 
tablished the  resonance  is  uniformly  intense.  With  the  excep- 
tion of  this  greater  intensity,  the  sound  is  exactly  similar  to 
that  obtainable  in  adults.  It  is  always  attended,  too,  by  a 
sensation  of  elasticity,  appreciated  by  the  finger  used  as  the 
pleximeter. 

"  Different  portions  of  the  thorax  possess,  normally,  different 
degrees  of  sonorousness. 

"  In  front,  the  right  side  is  markedly  resonant  from  the  clavicle 
down  to  the  fifth  interspace,  or  the  upper  border  of  the  sixth 
rib  in  the  mammary  line,  where  the  liver  dullness  begins.  On 
the  left  side  the  resonance  is  equally  intense,  but  it  is  en- 
croached upon  by  the  gastric  tympany,  which  extends  upward 
as  high  as  the  seventh  or  sixth  rib,  as  well  as  by  the  area  of 
cardiac  dullness.  The  latter  forms  an  irregular  triangle,  of 
which  one  side  is  represented  by  a  vertical  line  passing  down 
the  middle  of  the  sternum,  from  the  level  of  the  fourth  to  the 
sixth  rib ;  the  other,  by  an  oblique  line  touching  the  upper  ex- 
tremity of  the  first,  and  extending  outward  to  the  left,  and  down- 
ward, to  terminate  at  the  point  of  the  apex  beat ;  and  the  base, 
by  a  line  drawn  from  the  central  point  of  the  lower  edge  of 
the  sternum  (the  inferior  extremity  of  the  first  line),  along  the 
D.  C— 2 


18  THE  DISEASES  OF  CHILDREN. 

sixth  costal  cartilage  to  the  apex  of  the  heart.  Diminished 
resonance  and  elasticity  are  at  once  noticeable  when  the  per- 
cussion passes  from  the  lung  to  this  area,  though  the  precor- 
dial dullness  is  never  so  decidedly  marked  in  children  as  it  is  in 
adults. 

"  Laterally,  both  supra-axillary  regions  are  very  resonant. 
The  upper  portions  of  the  infra-axillary  regions  are  a  degree 
less  resonant,  and  the  lower  portions  are  dull  on  account  of 
the  presence  of  the  liver  on  the  right  and  the  spleen  on  the 
left  side.  The  superior  border  of  the  liver  dullness  is  found  in 
the  seventh  interspace  or  at  the  eighth  rib ;  that  of  the  spleen, 
at  the  upper  edge  of  the  ninth  rib.  Gastric  tympany  may  sup- 
plant the  pulmonary  resonance  over  the  left  infra-axillary 
region. 

"  Posteriorly,  there  is  little  resonance  in  the  scapular  region, 
particularly  the  supra-spinous  portions.  Over  the  inter-scapu- 
lar space  the  sound  improves,  but  it  is  less  resonant  than  anter- 
iorly or  laterally.  Over  the  infra-scapular  regions  the  reso- 
nance is  but  little  less  pure  than  in  front,  until  the  tenth  rib  is 
reached  on  the  right  side  and  the  liver  dullness  is  again  met 
with.  On  the  left  side  the  reasonance  extends  to  the  very 
base,  the  posterior  splenic  dullness  being  detected  with  dififi- 
culty.  The  right  base  is,  therefore,  naturally  less  resonant  than 
the  left,  and  this  difference  is  especially  marked  during  expira- 
tion, the  liver  rising  higher  at  that  time. 

"  Affections  of  the  lungs  produce  various  alterations  in  the 
percussion  sound.  The  chief  of  these  are  the  substitution  of 
tympany,  of  dullness  and  of  flatness  for  the  normal  resonance, 
and  of  increased  resistance  to  the  finger  for  elasticity.  Cardiac 
diseases  cause  changes  in  both  the  extent  and  the  shape  of  the 
area  of  precordial  dullness." 


CHAPTER  II. 

THERAPEUTIC   HINTS. 

The  opinion  is  very  widespread  that  because  no  fatal  cases 
of  narcosis  have  been  recorded  from  the  use  of  homeopathic 
drugs  that  the  remedies  we  employ  in  our  practice  are  entirely 
harmless  in  any  dose  and  frequency  of  repetition.  Our  fellow 
practitioners  of  the  older  school,  have  always  asserted  that  our 
attenuated  medicines  could  be  taken  by  the  pound  or  bucket-full 
without  fear  of  harm,  so  long  as  the  quantity  did  not  overtax 
the  distensive  capacity  of  the  patient's  stomach.  As  this  work 
is  not  written  with  a  missionary  purpose,  but  rather  to  instruct 
those  who  have  already  become  convinced  of  the  efficacy  and 
superiority  of  our  therapeutic  methods  and  measures,  no  argu- 
ment is  here  necessary  to  refute  so  erroneous  an  idea. 

Nothing  is  useful  that  cannot  be  abused,  and  while  homeo- 
pathic medicines  in  intelligent  and  skillful  hands  are  only  potent 
for  good,  there  are  some  drugs  in  common  use  by  practitioners 
of  homeopathy  that  should  be  given  to  children  with  great 
caution,  and  with  more  circumspection  than  would  be  deemed 
necessary  in  administering  them  to  adults.  It  may  be  remarked 
in  this  connection  that  a  marked  change  has  taken  place  in  the 
practice  of  homeopathic  physicians  everywhere,  within  the  last 
thirty  years — a  change  which  is  noticeable,  more  especially  in 
an  increase  of  dosage  and  a  growing  skepticism  regarding  the 
intensification  of  drug  action  from  dynamization — so  called. 

A  considerable  number  of  new  remedies  of  priceless  value, 
but  which  the  founder  of  our  system  never  heard  or  dreamed 
of,  have  been,  and  are  being,  added  to  our  pharmacopeia.  Many 
of  these  new  remedies,  if  not  all  of  them,  have  been  quite  gen- 
erally adopted  without  subjecting  them  to  the  exhaustive 
"  provings  "  that  obtained  in  the  Materia  Medica  Pura  of  Hahn- 
neman.  Such  practice,  it  is  freely  admitted,  is  more  or  less 
empirical,  but  clinical  experience  indorses  it,  and  only  the  nar- 
row-minded reject  it.  The  author  believes  that  he  voices  the 
sentiment  of  the  representative  members  of  our  school  of  prac- 
tice, in  saying,  that  at  the  present  time  we  do  not  regard  the 
therapeutic  law  of  similars  as  all-pervading — applicable  to  all 
cases  of  sickness  without  exception  or  reference  to  causation; 
nor  do  we  consider  a  drug  more  potent  for  good,  the  further  it 

(19) 


"20  THE  DISEASES  OF  CHILDREN. 

is  removed  from  the  form  in  which  it  is  found  in  nature.  We 
believe,  with  Dr.  J.  P.  Dake,  that  "  the  law  of  similars  is  not 
applicable  to  any  diseases  which  are  characterized  by  destruc- 
tion of  tissues,  or  where  the  cause  cannot  be  removed,  or  to 
such  as  are  due  to  chemical  action,  mechanical  violence,  or 
unhygienic  surroundings." 

Modern  pathology  has  shed  much  light  upon  the  nature  and 
causes  of  many  diseases,  and  shows  that  some  are  self-limited, 
and  tend  to  recovery  if  left  to  the  unaided  power  of  nature ; 
while  others  are  incurable  from  the  beginning  and  can  only  be 
palliated,  whatever  the  system  or  method  of  treatment. 

The  intelligent  physician  cannot  allow  a  dogma  to  close  his 
eyes  to  these  advances  in  medical  science,  nor  can  he  afford, 
from  mere  devotion  to  such  dogma,  to  allow  a  patient  to  suffer 
from  pain  which  can  be  alleviated,  but  cannot  be  cured.  The 
author  is  well  aware  of  the  fact  that  there  are  some  able  and 
intelligent  practitioners  of  homeopathy  who  look  askance  at 
these  modern  tendencies  and  innovations,  and  are  filled  with 
apprehensions  as  to  the  result.  The  number  of  such  persons, 
however,  is  small.  No  one  need  fear  the  light.  True  science 
cannot  retrograde.  Homeopathy  is  progressing  upward  and 
onward,  not  downward  or  backward.  In  the  following  pages 
remedies  will  sometimes  be  recommended  which  cannot  be  re- 
garded as  strictly  in  accordance  with  the  application  of  the  law 
of  similars,  but  which  are  sanctioned  by  experience,  which  is 
sometimes  paramount  to  law,  as  we  in  our  half-blindness  are  able 
to  see  and  construe  it.  But  it  is  not  the  province  of  this  work  to 
engage  in  polemics,  nor  to  discuss  questions  which  have  no  prac- 
tical import,  such  as  the  size  of  the  dose,  the  degree  of  attenu- 
ation, nor  the  alternation,  combination  or  repetition  of  reme- 
dies. The  author  prefers  to  leave  these  matters  to  the  fancy 
or  the  experience  or  the  teaching  of  the  individual.  It  is 
within  his  province,  however,  to  point  out  the  fact  that  there 
are  certain  drugs  which  the  combined  experience  of  the  profes- 
sion everywhere,  regardless  of  schools,  has  come  to  regard  as 
dangerous  when  given  to  the  young.  Over  forty  years  ago,  Dr. 
John  B.  Beck,  published  a  volume  of  "  Essays  on  Infant  Thera- 
peutics," etc.,  in  which  he  devotes  several  chapters  to  the  dan- 
ger of  giving  opium,  emetics  and  mercury  to  young  subjects. 
In  speaking  of  the  effects  of  opium  on  children,  he  cites 
numerous  cases  where  a  single  drop  of  laudanum  has  proven 
fatal  to  a  young  infant.  The  writer  himself  knows  of  several 
instances  of  death  resulting  from  what  was  regarded  as  a  per- 
fectly safe  dose  of  paregoric,  when  given  to  very  young 
children.  The  author's  coachman  lost  a  babe  a  week  old  from 
giving,  on  his  own  responsibility,  a  dose  of  a  much  advertised 


T^HERAPEUTIC  HINTS.  21 

patent  laxative  medicine.  Although  given  according  to  the 
printed  directions,  it  proved  fatal  in  less  than  an  hour.  A 
chemical  analysis  proved  that  it  contained  opium,  although  in 
its  advertisements  this  fact  was  ostentatiously  disclaimed.  If 
the  number  of  deaths  of  infants  and  children  from  anodynes, 
soothing  syrups  and  the  like,  were  known,  the  statement  of 
actual  facts  would  be  something  appalling.  We  have  seen  it 
stated  that  infants  have  been  ptyalized  by  mercury  when 
treated  by  followers  of  the  homeopathic  school.  If  this  be 
true,  it  could  only  be  by  the  grossest  carelessness  or  the  most 
inexcusable  ignorance.  It  may  be  well,  however,  to  state  that 
mercury,  even  in  our  usual  doses,  should  be  given  with  care 
and  not  be  continued  for  too  long  a  period.  Tartar  emetic  is 
another  remedy  of  the  greatest  value,  but  which  should  be 
given  with  great  care  to  young  children.  The  writer  once  saw 
a  child  affected  with  uncontrollable  emesis  from  this  drug 
given  in  the  third  decimal  trituration.  Since  that  time  he 
has  never  given  it  except  after  it  has  been  greatly  diluted  with 
water.  A  two-grain  powder  3*  trit.  should  be  dissolved  in 
half  a  glass  of  water  and  given  in  teaspoonful  doses  as  often  as 
required. 

The  propriety  of  giving  alcoholic  stimulants  to  children  is  a 
mooted  one.  In  diphtheria  of  a  malignant  type  we  have  seen 
good  results  from  the  exhibition  of  dilute  alcohol  used  as  a 
gargle,  and  of  whisky  taken  internally ;  and  even  in  cases  of 
very  young  children  affected  with  diphtheria,  we  have  given  it 
almost  to  the  point  of  intoxication.  In  some  of  the  rapidly 
wasting  diseases,  or  when  there  is  danger  of  sudden  collapse, 
alcoholic  stimulants  are  appropriate  and  useful.  But  the  habit 
of  giving  whisky  and  brandy  to  children  whenever  they  com- 
plain of  stomach  ache,  and  the  indiscriminate  use  which  is  made 
of  them  in  domestic  practice  cannot  be  too  severely  condemned. 
It  is  a  serious  question  whether  alcohol  in  medicine  has  not 
done  much  more  harm  than  good. 

Atropine  is  another  drug,  whose  action  should  always  be 
watched  when  administered  to  infants.  Even  when  given  in 
very  minute  doses  it  is  liable  to  produce  aggravations,  and  in 
susceptible  subjects  it  will  sometimes  produce  a  quasi-erythema 
confusing  to  the  neophyte.  What  has  just  been  said  of  atro- 
phine  holds  true  of  all  the  so-called  alkaloids.  They  should 
invariably  be  given  in  dilution,  that  is  to  say,  dissolved  in  water, 
rather  than  in  powder  form. 

The  use  of  so-called  "  tonics  "  is  one  that  is  greatly  abused. 
The  best  tonics  in  the  world  are  those  which  are  most  easily 
secured,  and  which  are  not  sold  at  either  the  drug  stores  or  the 
pharmacies,  viz.:  fresh  air  and  good  food.     Quinine  and  iron  in 


22  THE  DISEASES  OF  CHILDREN. 

9 

crude  doses  are  very  hard  of  digestion  by  the  average  infantile 
stomach,  and  when  they  are  indicated  our  second  or  third  deci- 
mal trituration  is  quite  strong  enough  for  all  practical  purposes. 
There  is  one  "tonic"  which  is  an  exception  to  what  has  just 
been  said.  Cod-liver  oil  should  not  be  classed  among  medi- 
cines, for  it  is  reall}^  a  food.  It  is  a  tonic,  because  all  digestible 
foods  are  tonics.  When  the  alimentary  canal  is  in  a  state  to 
absorb  it,  cod-liver  oil  is  oftentimes  of  immense  usefulness.  It 
should  be  remembered,  however,  that  the  power  of  digesting 
fats  in  early  life  is  not  great  and  for  this  reason  it  should  be 
given  tentatively  and  in  small  doses.  Two  or  three  drops  is 
enough  for  an  infant  under  six  months  of  age. 

In  cases  where  the  oil  is  not  assimilated  and  yet  seems  to  be 
indicated,  its  benefit  may  be  secured  by  inunction.  The  skin 
absorbs  it  with  great  readiness. 

Whatever  may  be  said  for  or  against  the  use  of  tonics  and 
stimulants,  there  can  be  no  two  opinions  about  giving  to  chil- 
dren the  new  coal-oil  products  known  as  anti-febrine,  anti-py- 
rine,  phenacetine,  sulphonal,  ef  id  ovine  genus.  Their  action  on 
the  adult  heart  is  not  without  danger,  and  they  are  altogether 
too  powerful  and  too  uncertain  in  their  action  to  give  to  chil- 
dren under  any  circumstances  or  in  any  dose. 

It  seems  to  have  been  forgotten  of  late  years  by  very  many 
physicians  that  the  most  efficient  anti-pyretic  in  the  world  is 
water.  By  the  proper  application  of  plain,  simple  water  in  dif- 
ferent temperatures  truly  wonderful  effects  can  be  produced. 
Dr.  Eustace  Smith,  in  his  excellent  work  on  "  Disease  in  Chil- 
dren "  (1884)  gives  some  admirable  directions  for  giving  baths 
with  a  view  to  getting  their  best  therapeutic  effects,  and  we 
quote  the  following  paragraphs : 

"The  question  of  reducing  temperature,  when  this  rises  to 
a  dangerous  height,  is  an  important  one.  Children  often 
bear  a  high  temperature  well,  and  it  is  not  always  easy  to 
say  what  degree  of  heat  constitutes  hyperpyrexia  in  a  child. 
When  the  fever  is  due  to  a  septic  cause  it  is  perhaps  less 
well  borne  than  when  it  is  the  consequence  merely  of  a  local 
inflammation. 

"  In  any  case,  if  the  temperature  rise  above  106°,  or  if  the 
patient  seem  to  be  distressed  by  a  less  degree  of  heat,  it  is  ad- 
visable to  sponge  the  surface  of  the  body  with  tepid  water. 
If  the  fever  be  not  reduced  by  this  means,  the  child  should  be 
placed  in  a  bath  of  the  temperature  of  75°,  and  be  kept  there 
until  the  pyrexia  undergoes  a  sensible  diminution.  Usually 
sponging  the  surface  will  reduce  the  bodily  heat  by  several  de- 
grees, to  the  immediate  relief  of  the  patient.  In  cases  of  in- 
flammatory diarrhoea,  even  in  babies  of  a  few  months  old,  the 


THERAPEUTIC  HINTS.  23 

temperature  often  rises  to    109°  or  1 10°,  and  the  child  passes 
into  a  state  of  profound  depression.     When  this  happens,  death 
is  inevitable  unless  the  pyrexia  can  be  quickly  reduced  ;  and 
tepid  bathing  is  often  successful  in  greatly  retarding,  if  it  do 65 
not  actually  prevent,  a  fatal  issue  to  the  illness. 

"  In  the  treatment  of  disease  in  early  life  the  remedies  at  our 
command  are  the  same  as  are  useful  for  similar  conditions  in 
the  adult.  On  account,  however,  of  the  impressible  nervous 
system  in  the  young  subject  external  applications  are  of  greater 
importance  in  childhood  than  they  become  in  after  years. 
Amongst  the  remedies  of  the  greatest  value  baths  form  a  class 
of  no  little  importance.  According  to  the  temperature  of  the 
water  employed  the  bath  becomes  a  sedative,  a  stimulant,  or  a 
tonic,  as  may  be  required  ;  and  in  these  different  shapes  is  often 
resorted  to  with  great  advantage.  The  usefulness  of  tepid 
bathing  in  reducing  fever  has  already  been  referred  to. 

"  The  warm  bath  (80°  to  85°  Fahr.)  is  very  useful  in  cases  of 
convulsions  or  great  irritability  of  the  nervous  system,  shown 
by  agitation,  restlessness,  spasm  or  disturbed  sleep.  It  calms 
the  excitement,  allays  spasm,  promotes  the  action  of  the  skin 
and  induces  sleep.  On  account  of  its  diaphoretic  effect  warm 
bathing  is  of  great  service  in  cases  of  Bright's  disease.  In  in- 
fants the  warm  bath  has  a  sensible  influence  in  promoting  the 
action  of  the  bowels,  and  in  cases  of  constipation  is  often  a  valu- 
able addition  to  purgative  medicines.  The  child  should  remain 
from  ten  to  twenty  minutes  in  the  warm  water. 

"  The  Jiot  bath  (95°  to  100°  Fahr.)  is  of  great  value  as  a  stimu- 
lant where  there  is  sudden  and  severe  prostration,  such  as  occurs 
in  cases  of  profuse  diarrhoea,  urgent  vomiting,  shock,  or  other 
cause  which  induces  a  temporary  depression  of  the  vital  ener- 
gies. When  employed  in  this  way  as  a  stimulant  the  child  must 
not  remain  too  long  in  the  water  or  the  stimulative  effect  will 
pass  off  and  be  succeeded  by  depression.  For  an  infant  three, 
and  for  an  older  child  five  minutes,  will  be  sufficient  immersion. 
The  patient  can  then  be  removed,  wiped  rapidly  dry,  and  laid 
between  blankets  with  a  hot  bottle  to  his  feet.  This  bath  may 
be  made  more  stimulating  by  the  addition  of  mustard.  Flour 
of  mustard,  in  the  proportion  of  one  ounce  to  each  gallon  of 
water,  is  mixed  up  with  a  little  warm  water  into  a  thin  paste 
and  placed  in  a  piece  of  muslin.  This  is  squeezed  in  the  hot 
water  until  the  latter  becomes  strongly  sinapised.  So  pre- 
pared, the  mustard  bath  is  an  important  remedy  in  cases  of 
prostration  and  collapse.  The  child  should  be  held  in  the 
bath  until  the  arms  of  the  attendant  supporting  him  begin 
to  tingle. 

"  The  cold  douclie  is  a  tonic  of  the  utmost  value.     It  must, 


24  THE  DISEASES  OF  CHILDREN. 

however,  be  employed  with  discretion,  for  the  patient  if  weakly 
seldom  obtains  a  proper  reaction  unless  special  precautions  be 
taken.  If  the  child  looks  blue  or  feels  chilly  after  the  bath, 
the  shock  to  the  system  has  been  too  violent.  For  a  weakly 
child  the  cold  douche  should  always  be  given  in  the  following 
way :  On  rising  from  his  bed  the  child  is  thoroughly  sham- 
pooed all  over  the  body,  using  steady  friction,  especially  to  the 
back  and  loins.  His  skin  being  thus  stimulated  and  prepared 
to  resist  the  shock  of  the  cold  water,  the  patient  is  made  to  sit 
in  a  few  inches  of  water  as  hot  as  he  can  conveniently  bear  it, 
and  then  immediately  a  pitcher  of  cold  water  (5  5°  to  60°)  is 
emptied  over  his  shoulders.  He  is  then  at  once  removed,  and 
well  rubbed  with  a  rough  towel  to  assist  reaction.  In  winter 
the  bath  should  be  placed  before  the  fire,  and  every  care  should 
be  taken  to  make  the  process  a  rapid  one.  The  shampooing 
will  occupy  from  ten  to  fifteen  minutes,  but  the  douche  should 
be  over  in  as  many  seconds.  It  is  well  to  allow  the  child  a 
drink  of  milk  or  a  biscuij:  before  beginning  the  process ;  and 
when  dried  the  chilcTmay  return  to  his  bed  for  a  short  time  if 
thought  desirable  ;  but  after  one  or  two  repetitions  of  the  bath 
this  precaution  will  be  unnecessary.  So  employed,  the  bath 
must  be  regarded  purely  as  a  therapeutic  agent,  and  not  as  a 
cleansing  process.  The  body  may  be  washed  in  the  ordinary 
way  at  night  before  the  child  is  put  to  bed. 

"  The  cold  douche  is  of  great  service  in  all  cases  of  weakness, 
whether  this  be  due  to  acute  or  chronic  illness,  and  is  only  in- 
admissible if  the  lungs  are  actively  diseased  or  there  is  fever. 
It  is  especially  useful  in  cases  of  long-standing  derangement 
and  in  the  scrofulous  cachexia,  and  may  be  recommended 
without  hesitation  for  children  of  very  fragile  appearance.  In 
addition  to  its  tonic  effect  the  bath  has  another  valuable 
quality  in  that  it  strengthens  the  resisting  power  of  the  body 
against  changes  of  temperature,  and  lessens  the  susceptibility 
to  cold." 

The  wet  sheet  pack  is  a  valuable  means  of  exciting  diapho- 
resis, as  in  post-scarlatinal  dropsy,  and  for  equalizing  the  circu- 
lation under  any  circumstances.  It  should  be  given  in  the 
following  manner:  The  bed  is  first  prepared  by  being  spread 
with  several  layers  of  woolen  blankets.  Then  while  the  child 
is  being  stripped  an  attendant  should  wring  out  a  cotton  sheet 
which  has  been  immersed  in  a  bucket  of  boiling  hot  water. 
The  water  must  be  very  hot  or  the  wet  sheet  will  be  cold  before 
the  patient  can  be  wrapped  up  in  it.  The  sheet  should  then 
be  quickly  spread  on  the  open  blankets  and  the  child  wrapped 
up  in  it,  leaving  only  the  head  exposed.  Now  the  blankets 
should  be  brought  over  and  tucked  in  all  around  as  snugly  as 


THERAPEUTIC  HINTS.  25 

may  be.     A  cloth  wet  in  cold  water  should  be  placed  on  the 
head  and  left  there  as  long  as  the  pack  is  continued. 

The  duration  of  the  pack  is  to  be  decided  by  circumstances. 
It  may  last  from  fifteen  or  twenty  minutes  to  an  hour  or 
more.  If  the  child  drops  asleep  it  may  be  left  undisturbed  un- 
til it  awakens.  When  taken  out  the  cool  sponge  should  be 
used,  or  the  douche,  as  described  above." 


CHAPTER    III. 

DISEASES  AND  ACCIDENTS  IMMEDIATELY  FOLLOWING  BIRTH. 

We  have  already  referred  to  the  changes  which  take  place  in 
the  circulation  at  the  moment  of  birth,  and  this  momentous 
change  from  a  dependent,  parasitic  life  to  an  independent  exist- 
ence is  usually  inaugurated  without  trouble  or  accident.  But 
it  is  not  always  so.  Occasionally  the  lungs  fail  to  expand  and 
the  mother's  heart  fails  to  be  gladdened  by  the  sound  of  the 
first  cry  of  the  new  born. 

Sometimes  the  child,  the  victim  of  disease  or  starvation  in 
utero,  is  born  in  such  a  state  of  debility  as  to  be  too  weak  to 
cry.  Sometimes  it  is  apparently  dead  and  sometimes  really  so 
— still-born.  In  cases  of  asthenia,  the  infant  lacks  the  red  color 
of  health  and  is  pale,  at  times  blue ;  its  features  are  shrivelled 
and  its  body  emaciated.  Under  these  circumstances  it  would 
be  quite  improper  to  subject  the  weakling  to  the  same  treat- 
ment that  would  be  appropriate  for  the  strong  and  healthy. 
At  times  this  state  of  debility  is  so  great  that  it  is  best  to  post- 
pone the  washing  and  dressing,  which  otherwise  should  be  done 
as  soon  as  practicable  after  birth.  All  that  can  be  done  is  to  en- 
velop it  in  hot  flannel,  or  better  still  in  hot  carded  cotton  or 
wool.  If,  however,  the  child  is  not  too  weak  it  may  be  greaaed 
•and  washed — a  little  whisky  or  alcohol  being  added  to  the 
water,  which  should  be  as  hot  as  can  be  borne,  say  i  io°  to  120° 
Fahrenheit. 

These  feeble  infants  bear  a  very  high  degree  of  heat.  All 
obstructions  to  respiration  should  previously  have  been  re- 
moved by  carefully  wiping  out  the  buccal  cavity,  and  if  there  be 
any  suspicion  of  obstruction  in  larynx  or  trachea,  the  expedi- 
ent may  be  resorted  to  which  is  often  successful,  to  hold  the 
child  by  the  lower  extremities,  with  its  head  down,  and  then 
to  shake  it  briskly,  or  spank  it  sharply  on  the  nates ;  a  sud- 
den inspiration  is  thus  evoked,  followed  by  a  cough  which  may 
remove  the  whole  trouble. 

If  this  fails,  measures  should  be  taken  to  increase  as  speedily 
as  possible  the  strength  of  the  child  until  it  can  take  a  full  in- 
spiration.    To    this  end   stimulating   nourishment    should    be 
given,  a  little  at  a  time,  but  frequently. 
(26) 


DISEASES  FOLLOWING  BIRTH.  27 

A  little  cream,  diluted  with  hot  water  to  which  a  little  whisky 
may  be  added,  is  best.  The  child  is  too  weak  to  nurse,  and  yet 
it  must  have  food.  A  teaspoonful  of  whisky  or  brandy  may  be 
added  to  five  or  six  teaspoonfuls  of  hot  water,  slightly  sweet- 
ened, and  this  given  every  few  minutes  in  half-teaspoonful 
doses  for  a  time.  In  this  way  some  of  these  lives  may  be  saved. 
But  unfortunately  others  will  fail  to  respond  to  the  stimuli  and 
become  colder  and  colder,  and  bluer  and  bluer ;  their  respira- 
tion becomes  more  and  more  feeble,  until  it  finally  ceases 
altogether. 

But  besides  these  cases  of  feebleness  at  birth,  it  sometimes 
happens  that  a  child  plump,  well  nourished  and  perfectly 
formed  is  still-born,  due  to  a  state  of  asphyxia  from  compres- 
sion of  the  umbilical  cord  or  from  breech  presentation  ;  from 
premature  detachment  of  the  placenta,  or  other  accidents  in- 
cidental to  labor. 

Sometimes  an  apoplectic  condition  of  the  child  is  found — a 
congestion  of  the  brain  and  the  blood  vessels  leading  thereto 
producing  a  paralytic  condition  of  the  respiratory  nerves,  which 
under  these  conditions  fail  to  respond  to  the  stimulus  of  the 
air  after  being  brought  into  the  world  and  prompt  measures 
must  be  employed  or  apparent  death  may  speedily  become  an 
actuality.  The  signs  of  this  condition  are  swollen  features  and 
face  red  or  purplish  blue.  When  this  condition  is  observed  and 
the  child  does  not  breathe,  no  time  should  be  lost  in  letting  a 
few  drops  of  blood  escape  from  the  cut  extremity  of  the  cord. 
This  expedient  tends  to  relieve  the  congestion  of  the  brain  and 
to  equalize  the  general  circulation. 

Brisk  rubbing  of  the  body  should  next  be  resorted  to ;  slap- 
ping the  nates  ;  plunging  the  body  alternately  into  hot  and  cold 
water ;  and  if  these  means  fail  recourse  must  then  be  had  to  ar- 
tificial respiration.  This  is  best  accomplished  as  follows  :  The 
child  should  be  placed  on  its  side  in  such  a  position  that  the 
epiglottis  falls  forward  ;  a  towel  or  napkin  should  be  wrapped 
around  the  child's  mouth,  leaving  an  opening  through  which 
the  operator  can  blow  his  breath.  In  the  meanwhile  compres- 
sion should  be  made  on  the  epigastrium.  A  little  air,  notwith- 
standing the  compression,  will  enter  the  stomach,  and  some  will 
escape  by  the  nostrils,  but  the  rest  will  enter  the  lungs.  Im- 
mediately the  hand,  passing  from  the  epigastrium  to  the  thorax, 
compresses  it  gently,  though  with  sufficient  force  to  produce 
expiration.  This  should  be  repeated  six  or  eight  times  per 
minute.  Very  soon  in  many  cases  the  heart's  action,  previously 
slow  or  almost  imperceptible,  will  be  quickened  and  resuscita- 
tion will  sometimes  be  successful,  even  when  the  heart  had 
ceased  to  beat  for  a  considerable  time.     The  physician  should 


28  THE  DISEASES  OF  CHILDREN. 

not  abandon  hope  in  these  cases  until  artificial  respiration  has 
been  continued  for  at  least  half  an  hour.  Dr.  Penrose  cites  a 
case  when  success  rewarded  effort  after  an  hour  and  a  half*  It 
matters  not  how  small  the  proportion  of  these  cases  respond  to 
our  efforts,  the  duty  is  imperative  and  the  number  of  resusci- 
tations is  sufficiently  large  to  encourage  our  hopes  and 
stimulate  our  zeal. 

Caput  Succedaneum;  Cephalhematoma. — Extravasation 
of  blood  into  that  part  of  the  scalp  which  presents  during  birth 
occasionally  occurs,  owing  either  to  the  duration  of  the  labor 
or  the  intensity  of  the  uterine  contractions.  The  term  "caput 
succedaneum,"  is  the  term  employed  to  designate  the  swell- 
ing on  the  head  when  thus  caused.  Its  seat  is  in  the  loose 
connective  tissue  of  the  scalp,  and  is  external  to  the  pericra- 
nium. The  tumor  is  soft,  painless  and  usually  located  upon 
the  occiput.  It  consists  mostly  of  serum  or  serum  mixed  with 
extravasated  blood.  This  exudation,  being  in  the  loose  connec- 
tive tissue  as  just  stated,  produces  no  discomfort  to  the  child 
and  except  its  unsightliness  is  a  matter  of  little  moment.  It  is 
quickly  absorbed  and  usually  does  not  last  more  than  two  or 
three  days.     It  does  not  require  any  treatment. 

A  somewhat  different  condition  exists  in  what  is  called 
cephalhematoma.  Here  the  blood  and  serum  are  extravasated 
under  the  pericranium  as  well  as  above  it,  and  we  not  only  have 
the  caput  succedaneum  just  described,  but  underneath  it  a 
tumor  which  is  observed  when  the  other  declines.  It  is  usually 
found  upon  the  occipital  or  parietal  bones,  near  the  posterior 
fontanels.  Being  situated  under  the  pericranium,  it  separates 
this  from  the  bone,  but  owing  to  the  resistance  it  meets  with 
in  the  firmly  attached  membrane,  it  does  not  spread  far  and 
rarely  crosses  a  suture.  This  tumor  is  not  so  readily  absorbed 
as  the  former,  and  is  therefore  more  permanent,  not  disappear- 
ing oftentimes  for  several  weeks.  Indeed,  after  the  lapse  of 
several  months  a  slight  prominence  may  be  detected,  indicat- 
ing the  seat  of  the  tumor.  This  is  occasioned  by  the  fact  that 
the  pericranium  does  not  lose  its  vitality  from  being  separated 
from  the  bone,  but  continues  to  perform  its  functions  and  a 
ring  of  new  bone  formation  is  the  result.  This  can  be  readily 
detected  by  the  finger,  as  it  surrounds  the  base  of  the  tumor. 
This  new  bone  is  thin  and  flexible  at  first,  but  becomes  firmer 
as  absorption  goes  on.  It  ultimately  disappears,  leaving  only 
a  faintly  defined  thickening  over  its  seat. 


*See  Cyclopedia  of  Diseases  of  Children,  vol.  i,page  249. 


UMBILICAL  HEMORRHAGE.  29 

Umbilical  Hemorrhage. — Besides  the  profuse  and  even 
fatal  hemorrhages  which  occur  at  birth  or  soon  after  from  care- 
less ligature  of  the  umbiHcal  cord,  there  is  another  form  of  um- 
bilical hemorrhage  in  which  the  accoucheur  is  in  no  wise 
responsible.  Over  three  hundred  cases  of  the  kind  have  been 
reported  from  time  to  time  in  the  various  medical  journals  and 
reports,  and  their  causes  have  been  studied  by  such  accurate  ob- 
servers as  Dr.  Francis  Moriat,  Prof.  Stephen  Smith  and  Dr.  J. 
Foster  Jenkins.  Their  investigations  brought  out  the  following 
results : 

^'■Causes. — The  common  proximate  cause  is  feeble  coagulabil- 
ity of  the  blood.  In  the  normal  state,  when  the  cord  is  ligated, 
the  fibrin  of  the  blood,  which  now  ceases  to  flow  in  the  umbil- 
ical vessels,  forms  coagula  so  firm  that,  by  the  time  the  cord  is 
detached,  hemorrhage  is  impossible.  But  in  the  majority  of 
those  affected  with  this  disease,  the  clots  are  so  soft  and  loose 
that  they  do  not  present  any  effectual  barrier  in  the  pressure 
of  blood,  which  therefore  oozes  through  them  or  presses  them 
away.  This  lack  of  coagulability  is  easily  demonstrated,  for  if 
a  little  blood,  as  it  escapes,  is  caught  in  a  vessel,  it  will  be  found 
to  remain  liquid  a  long  time.  This  dyscrasia,  or  morbid  state 
of  the  blood,  which  we  therefore  recognize  as  a  chief  cause  of 
the  hemorrhage,  does  not  have  the  same  origin  in  all  cases.  It 
is  sometimes  due  to  inherited  syphilis.  The  infant  affected 
with  it  may  be  plump,  and  appear  well  at  birth,  but  in  most  in- 
stances, when  the  hemorrhage  is  to  occur,  it  is  puny  and  ca- 
chectic, exhibiting  also  local  manifestations  of  the  disease  with 
which  it  is  affected.  Thus,  in  a  case  in  my  practice,  the  infant, 
puny  and  apparently  born  before  term,  was  observed  to  have 
several  blebs  of  pemphigus  on  the  first  day,  from  some  of  which 
blood  began  to  ooze,  but  the  fatal  umbilical  hemorrhages  did 
not  commence  till  after  two  weeks. 

"In  about  one-fifth  of  the  cases  ecchymoses  or  petechie  have 
been  observed  upon  various  parts  of  the  surface,  affording  ad- 
ditional proof  of  the  general  blood  disease. 

"  Jaundice  is  another  cause  of  impoverishment  of  the  blood  in 
the  new-born,  and  therefore  of  umbilical  hemorrhage.  The 
writers  who  have  collected  records  of  the  hemorrhage,  all  re- 
mark the  frequent  occurrence  of  the  icteric  hue,  both  before 
and  during  the  bleeding.  It  is  not  improbable  that,  in  certain 
instances,  the  jaundice  is  hematogenous,  arising  from  destruc- 
tion of  the  red  corpuscles  and  liberation  of  the  hematin,  a  not 
unusual  result  of  a  profound  dyscrasia,  whether  syphilitic  or 
originating  in  some  other  cause.  But  in  other,  and  probably 
most  instances,  the  jaundice  proceeds  from  the  liver,  and  is 
the  cause  of  the  change  in  the  blood.     Thus,  in  five  of  Jen- 


30  THE-  DISEASES  OF  CHILDREN. 

kin's  cases,  there  was  occlusion  of  the  hepatic  or  common  bile- 
ducts,  and  jaundice,  from  the  presence  of  biliary  acids  in  the 
blood,  causes  diminution  in  the  amount  of  fibrin  and  red  cor- 
puscles. In  the  ordinary  form  of  icterus  neonatorum,  the  cause 
of  which  is  found  in  the  relative  fullness  of  the  capillaries  and 
minute  bile-ducts  in  the  acini  of  the  liver,  the  coagulability  of 
the  blood  must  evidently  be  impaired  in  proportion  to  the  de- 
gree and  duration  of  the  jaundice. 

"  Poor  health  of  the  mother,  and  impoverishment  of  her  blood 
during  gestation,  whether  from  chronic  disease,  as  tuberculosis, 
or  anti-hygienic  conditions,  also  cause  impoverishment  and 
diminished  coagulability  of  the  blood  of  the  child,  and  are 
therefore  causes  of  the  hemorrhage.  The  excessive  use  of 
diluent  drinks  or  alkalies  by  the  mother  is  believed  by  some  to 
have  a  similar  effect. 

"  In  certain  cases  the  hemorrhage  is  due  to  an  inherited  hem- 
orrhagic diathesis.  In  nine  of  Jenkins'  cases  the  mothers 
were  subject  to  menorrhagia,  and  liable  to  bleed  freely  after 
parturition,  and  from  injuries ;  and  seventeen  other  mothers 
had  each  lost  more  than  one  infant  from  umbilical  hemorrhage. 
Probably  in  those  cases  in  which  the  hemorrhage  commences 
before  detachment  of  the  cord,  and  external  to  its  point  of 
insertion,  the  hemorrhagic  diathesis  is  the  main  cause  of  the 
flow. 

"Although  the  cause  of  umbilical  hemorrhage  in  the  majority 
of  cases  is  the  vitiated  state  of  the  blood  itself,  observers, 
among  others  the  late  Sir  James  Y.  Simpson,  have  met  with 
cases  in  which  the  hemorrhage  was  referable  to  the  state  of 
the  vessels.  In  order  that  the  vessels  be  effectually  closed  by 
the  fibrinous  coagula,  their  walls  should  have  their  normal  con- 
tractility, but  this  is  in  great  part  lost,  by  inflammation  (arter- 
itis or  phlebitis)  which  sometimes  occurs  in  these  vessels,  as 
we  have  already  seen.  Inflammation,  whether  of  artery  or 
vein,  causes  thickening  and  infiltration  of  its  parietes,  loss  of 
tone  on  the  part  of  the  fibres  of  which  they  are  composed, 
and  therefore,  a  patulous  state  of  the  vessel  ;  moreover,  the 
inflammation  is  apt  to  be  suppurative  and  the  presence  of  pus 
in  the  vessel  obviously  hinders  the  formation  of  a  firm  and 
effective  coagulum." 

Symptoms. — Ordinarily,  umbilical  hemorrhage  occurs  without 
any  premonition,  but  sometimes  it  is  preceded  by  jaundice. 
Jenkins  ascertained  that  jaundice  was  a  prodormic  symptom  in 
41  out  of  178  cases,  and  besides  the  icteric  hue,  constipation, 
clay-colored  stools,  deeply-tinged  urine,  etc.,  were  sometimes 
recorded.  Rarely  colicky  pains  and  vomiting  preceded  the 
hemorrhage.     The  blood  may  be  arterial  or  venous,  or  both. 


UMBILICAL  HEMORRHAGE.  31 

It  oozes  slowly  or  rapidly,  rarely  escaping  in  a  jet,  even  where 
there  is  reason  to  believe  that  it  is  arterial. 

Prognosis. — This  is  unfavorable.  Statistics  show  that' five 
in  every  six  perish.  The  prognosis  is  most  unfavorable  when 
jaundice  or  purpura  is  present.  Those  are  most  likely  to  re- 
cover who  have  a  healthy  parentage,  no  obvious  dyscrasia,  and 
in  whom  the  hemorrhage  occurs  late  and  is  not  profuse.  The 
average  duration  of  the  hemorrhage  in  82  fatal  cases  in  Jenkins* 
collection  was  three  and  one-half  days,  the  minimum  being 
three  hours.  After  the  arrest  of  the  hemorrhage  death  may 
occur  from  exhaustion  or  the  dyscrasia. 

Treatment. — But  little  can  be  done  for  these  cases  medicin- 
ally. The  bowels,  which  are  usually  constipated,  should  be 
kept  open  by  enemata,  and  the  jaundice  treated  by  the  reme- 
dies suitable  to  that  condition.  The  modes  of  treating  the 
bleeding  parts  have  been  various.  Those  most  deserving  of  men- 
tion are  the  following :  Injecting  a  styptic  into  the  open  ves- 
sels, applying  a  styptic  by  compress  or  sponge  to  the  navel, 
covering  the  navel  with  dry  or  wet  plaster  of  paris,  constant 
pressure  with  the  finger,  which  is  tedious,  but  which  maternal 
solicitude  willingly  provides,  and  lastly,  the  use  of  needles 
with  ligature.  All  of  these  methods  have  been  more  or  less 
successful  in  arresting  the  hemorrhage,  but  the  last  is  most 
effectual,  though  painful.  Two  needles  should  be  passed 
through  the  umbilicus  at  right  angles,  and  a  waxed  thread 
wound  around  each  in  the  form  of  a  figure  eight.  In  four  or 
five  days  the  needles  should  be  removed  and  a  poultice  or  sim- 
ple dressing  applied. 


CHAPTER  IV. 

FOOD  AND  FEEDING. 

Every  new-born  child,  when  it  comes  into  the  world,  brings 
with  it  an  iteration  of  tlie  old  problem,  "wherewithal  shall  it 
be  fed?"  and  we  cannot  avoid  the  question  long,  for  if  the  babe 
be  healthy,  it  will  soon  cry  aloud  for  sustenance.  The  fires  of 
life  must  be  kept  burning ;  its  ever  wasting  secretions  must  be 
made  good ;  material  for  repair  and  for  growth  must  be  con- 
stantly provided,  or  the  organism  will  soon  perish.  When  the 
mother  is  in  good  health  and  has  an  adequate  supply  of  milk, 
or  when  in  lieu  of  this,  a  young  and  healthy  wet-nurse  can  be 
secured,  the  question  of  nourishment  is  easily  settled,  for  there 
is  no  diversity  of  opinion  as  to  the  advantage  of  breast  milk, 
and  its  superiority  over  every  other  kind  of  food,  always  pro- 
vided, however,  that  the  milk  furnished  by  the  breast  of  the 
mother  or  the  wet-nurse  proves  on  trial  to  agree  with  the  child. 
Be  it  known  that  it  is  not  every  woman  whose  milk  agrees  with 
a  new-born  babe.  We  have  a  case  in  mind  that  very  clearly 
demonstrates  this  fact.  Some  years  ago  we  attended  a  woman 
some  thirty-five  years  of  age  in  her  third  confinement.  The 
babe  was  born  at  full  term,  and  was  a  strong,  plump,  ruddy  in- 
fant. The  mother  was  a  type  of  physical  health  and  strength. 
She  had  ample  breasts  with  well-formed  nipples,  but  she  in- 
formed me  that  she  could  not  nurse  her  children.  I  learned 
from  her  that  her  first  child  was  a  puny  weakling  during  all  the 
time  she  nursed  it,  and  did  not  thrive  and  grow  until  after  it 
was  weaned  when  a  year  old ;  her  second  child,  although  large 
and  plump  at  birth,  was  nursed  by  her  until  it  died  at  eight 
months  of  age.  It  declined  steadily  from  the  time  it  was  born 
until  death.  Notwithstanding  this  discouraging  history,  I 
urged  her  to  try  it  again,  and  she  readily  agreed  to  make  the 
experiment.  In  due  time  she  had  an  abundant  flow  of  milk, 
and  I  had  it  carefully  analyzed.  Not  a  fault  could  be  found 
with  it.  It  was  up  to  the  standard  in  every  respect.  The  babe 
took  the  breast  eagerly,  and  for  a  week  all  went  well.  It  neither 
gained  nor  lost  in  weight ;  but  in  the  second  week  it  became 
fretful  and  peevish,  cried  almost  continually,  and  lost  a  pound 
in  weight.  Again  I  had  the  milk  analyzed,  with  the  same  re- 
sult as  before.  It  answered  to  every  test,  and  was  pronounced 
(32) 


FOOD  AND  FEEDING.  88 

perfect  in  every  respect.  But  the  baby  steadily  lost  ground, 
and  at  the  end  of  three  weeks  was  put  on  artificial  food.  It 
was  not  until  after  six  months  that  it  began  to  grow  and  thrive 
as  it  should.  It  is  now,  however,  at  the  age  of  eight  or  nine 
years,  a  strong,  full-sized  and  healthy  girl.  I  learned  a  lesson 
from  this  case  that  has  been  of  much  service  to  me  since  then, 
viz.,  that  the  baby  is  itself  the  best  and  the  only  sure  test  of 
food,  whether  it  be  natural  or  artificial.  Indeed,  the  funda- 
mental principle  of  feeding  is  to  adapt  the  food  to  the  wants 
and  the  capacity  of  the  individual  infant.  It  will  not  do  to 
have  any  rigid  and  inflexible  rules.  Precedent  is  apt  to  mis- 
lead ;  tables  of  nutritive  equivalents  are  worthless  ;  chemical 
analysis  is  valueless. 

There  is  a  vital  chemistry  which  is  too  subtle  for  the  labora- 
tory ;  changes  and  physical  alterations  occur  in  food  which  are 
too  delicate  for  tests  or  analysis ;  and  yet  they  make  all  the 
difference  between  digestion  and  indigestion — between  assimi- 
lation and  non-assimilation — between  life  and  death.  Trial  is 
the  only  touchstone,  experiment  the  only  guide  that  will  lead 
us  in  safe  paths.  That  organic  chemistry  is  incompetent  to 
pass  on  the  question  of  foods  at  all  times — that  it  is  liable  to 
mislead  at  any  time  unless  its  physiological  peculiarities  are  also 
considered,  is  evident  from  certain  well-known  facts.  For  ex- 
ample, milk  that  has  undergone  change,  that  is  "turned,"  is  re- 
garded, and  very  justly  so,  as  unfit  to  be  taken  into  a  baby's 
stomach  as  food  ;  and  yet,  no  sooner  is  fresh,  sweet  milk  taken 
into  the  stomach  than  lactic  acid  is  formed  and  the  milk  is 
"  curdled." 

The  milk  is  not  assimilable  until  this  change  takes  place ; 
but  it  must  take  place  within  the  stomach  and  not  out  of  it. 
Again,  chemistry  teaches  us  that  all  foods  are  divisible  into 
the  nitrogenous  and  non-nitrogenous,  and  that  the  former 
are  the  plastic  or  tissue-forming  elements,  while  the  latter 
are  respiratory  or  heat-producing  merely.  The  natural  in- 
ference is  that  the  one  class  of  elements  is  far  more  essential 
to  the  organism  than  the  other.  And  yet  the  fact  is  that 
not  a  cell  nor  a  fiber  can  be  formed,  nor  can  they  subsist, 
without  a  certain  amount  of  fats  and  salts.  Not  a  tissue 
can  come  into  being,  nor  continue  its  functions,  without  a 
large  proportion  of  non-r\\\.rogtno\xs  materials  —  a  propor- 
tion greatly  exceeding  the  nitrogenous.  If  the  proteids  are 
a  sifie  qua  7ion,  so  also  are  fats,  water  and  salts.  When 
chemistry  teaches,  as  it  does,  that  "  only  nitrogenous 
substances  are  capable  of  conversion  into  blood,"  it 
teaches  a  palpable  fallacy  and  leads  us  at  once  into  a  maze 
of  error. 

D.  C— 3 


34  THE  DISEASES  OF  CHILDREN. 

We  have  said  this  much  to  illustrate  the  statement  that,  be- 
cause the  milk  of  the  mother  or  the  wet-nurse  is  able  to  pass 
muster  when  subjected  to  chemical  analysis,  it  does  not  there- 
fore follow  that  it  must  and  does  fulfill  all  the  requirements 
for  the  nourishment  of  the  new-born  child.  The  child's  stom- 
ach offers  a  better  and  higher  test. 

Such  instances  as  that  narrated,  when  not  only  one  but  seve- 
ral children  have  failed  to  be  nourished  by  the  milk  of  a  robust 
mother,  are  exceptional,  but  they  do  occur  and  it  is  proper  the 
student  and  the  young  practitioner  should  be  made  acquainted 
with  the  fact.  Other  cases  there  are,  and  these  are  far  more 
common,  where  mothers  are  fully  able  and  willing  to  nurse  their 
offspring,  but  who  should  never  be  permitted  to  do  so,  if  the 
future  well-being  of  the  child  is  properly  considered.  The  dan- 
ger of  aggravating  or  transmitting  constitutional  taints  through 
nursing  is  universally  admitted.  That  only  healthy  mothers 
should  nurse  their  young  is  so  palpably  true  that  the  bare  state- 
ment of  the  fact  is  sufficient.     But  as  Dr.  Jacobi  well  says  :* 

"  Health  is  a  relative  term,  and  the  general  health  of  the 
body  is  quite  compatible  with  defective  development  of  one  or 
more  of  its  parts.  Thus,  even  well-formed  breasts  may  contain 
diminutive  milk  glands,  whose  imperfection  is  concealed  by  the 
abundant  adipose  tissue  lying  under  the  skin.  Again,  the 
glands  may  be  sufficiently  large,  yet  their  activity  be  continually 
interfered  with  by  the  irritable  condition  of  the  nervous  sys- 
tem. •  .  .  The  evil  influence  of  an  excitable,  nervous 
temperament  may  be  manifested  in  the  quality  of  the  milk, 
which,  under  violent  emotions,  may  be  so  altered  as  to  become 
a  positive  poison  to  the  child. 

"Generally  the  effects  of  such  alteration  are  confined  to  digest- 
ive disturbances,  to  vomiting,  colic,  purging.  But  in  some 
rare  instances,  whose  record  is  famous,  a  child  put  to  the  breast 
of  a  woman  still  agitated  by  violent  excitement,  has  been  seized 
with  convulsions,  or  has  died  suddenly,  without  the  warning  of 
any  sym.ptoms  whatever.  In  these  cases  a  virulent  ferment 
seems  to  have  been  generated  in  the  milk,  analogous  in  the  in- 
tensity of  its  action  to  that  formed  in  the  saliva  of  a  hydropho- 
bic dog,  and  whose  malignancy  varies  according  to  its  abun- 
dance and  to  the  mass  of  milk  that  had  been  decomposed  under 
its  influence. 

"  For  these  reasons,  a  woman  with  a  markedly  nervous  tem- 
perament is  generally  unsuitable  for  the  office  of  nursing,  since 
her  milk  is  liable  to  become  deficient  in  quantity  or  perverted 
in  quality." 


•"Infant  Diet,"  i5 


WOMEN  WHO  SHOULD  NOT  NURSE.  35 

Where  the  child  is  born  with  a  harelip  or  a  cleft  palate,  there 
is  an  impediment  to  nursing  on  the  part  of  the  child  that  is  in- 
superable. To  understand  this  it  is  necessary  to  comprehend 
the  mechanism  of  suction. 

Again  we  quote  from  Dr.  Jacobi :  "  When  the  child  seizes  the 
nipple,  the  lips,  fitting  accurately  around  it,  close  the  cavity  of 
the  mouth  in  front,  while  behind,  this  cavity  is  closed  by  the 
soft  palate,  which  falls  like  a  curtain  upon  the  root  of  the 
tongue.  The  tongue  arches  so  as  to  touch  the  roof  of  the 
mouth,  and  the  cavity  is  thus  completely  filled  up,  as  the  cyl- 
inder of  a  pump  is  filled  by  the  piston.  When  the  child  begins 
to  suck,  the  tongue  is  drawn  back,  just  as  the  piston  would  be, 
and  for  the  same  purpose,  to  create  a  vacuum  in  the  space  left 
between  its  tip  and  the  lips.  Into  this  vacuum  the  milk  is  forced 
by  the  pressure  of  the  atmosphere  on  the  breast. 

"As  soon  as  the  space  is  filled,  the  milk  is  thrown  to  the  back 
of  the  mouth  by  the  tongue,  which  abandons  for  this  purpose 
its  office  as  piston,  the  soft  palate  is  lifted  up  to  a  level  with 
the  roof  of  the  mouth,  thus  closing  the  communication  with  the 
nose,  and  the  milk  falls  into  the  throat,  there  exciting  automa- 
tic contractions  of  the  pharynx,  that  occasion  a  distinct  sound 
of  deglutition.  This  movement  of  deglutition  alternates  there- 
fore with  that  of  suction." 

When  the  tongue  is  "  tied,"  i.  e.,  bound  down  to  the  floor  of 
the  mouth,  it  is  easily  seen  that  the  act  of  suction  cannot  be 
accomplished  until  the  defect  is  remedied.  It  cannot  retreat 
sufficiently  to  act  as  a  piston.  This  impediment  is  easily  re- 
moved by  snipping  the  frenutn  linguce  sufficiently  to  release 
the  tongue.  This  should  be  done  with  a  pair  of  blunt-pointed 
scissors,  care  being  taken  not  to  cut  too  far  back  for  fear  of 
injuring  a  branch  of  the  lingual  artery.  Where  the  mother's 
nipples  are  absent,  from  accident  or  disease,  or  are  illy 
formed,  it  is  often  a  fruitless  task  to  remedy  the  defect  suffi- 
ciently to  enable  her  to  nurse  successfully.  No  shield  or 
artificial  nipple  is  made  that  can  be  fully  relied  upon.  It  is 
better  to  abandon  the  effort  in  the  beginning.  This  statement 
does  not  apply  to  nipples  that  are  merely  depressed,  as  we  shall 
see  presently. 

Women  who  Should  not  Nurse.— But  a  constitutional 
disease  in  the  mother  and  some  acute  morbid  conditions  are  a 
barrier  to  nursing  that  cannot  be  ignored.  The  blood  of 
rheumatic  women  contains  an  excess  of  lactic  acid,  and  their 
milk  will  inevitably  create  a  ferment  in  the  child's  stomach 
disastrous  to  its  health.  The  children  of  such  women  are 
proverbially    illy   nourished,    undersized,   thin    and    nervous. 


36  THE  DISEASES  OF  CHILDREN. 

When  the  mother  is  anemic — that  is  to  say,  when  her  blood  is 
impoverished  from  deprivation  or  overwork — the  solid  constitu- 
ents of  the  milk  are  necessarily  diminished.  The  milk  is  thin 
and  watery  and  more  or  less  wanting  in  the  essentials  of  full 
nutrition.  Consumption,  syphilis,  epilepsy,  scrofula,  cancer, 
are  all  so  readily  transmissible  as  to  be  prohibitory  if  one  ex- 
pects the  child  to  grow  to  healthy  maturity.  Chronic  eruptions 
should  probably  be  put  into  the  same  category,  for  the  obvious 
reason  that  out  of  pure  blood  can  we  alone  expect  pure  milk. 
Mania,  if  it  amounts  to  insanity,  renders  the  act  of  nursing  too 
precarious  or  even  dangerous  to  be  permitted.  The  essential 
fevers,  if  of  a  mild  type,  which  do  not  affect  the  mother's  rea- 
son, nor  interfere  with  the  flow  of  milk,  need  not  interfere  with 
the  performance  of  the  functions,  especially  if  they  be  not  so 
prolonged  as  to  greatly  exhaust  the  strength  and  imperil  life. 
Erysipelas  is  a  disease  that  appears  to  affect  the  milk  badly 
and  render  it  unfit  for  nursing.  There  are  cases  recorded  of 
this  disease  occurring  during  lactation  in  which  the  results  to 
the  infant  were  fatal. 

Suppurative  inflammation  of  the  breast  offers  sufficient  rea- 
son for  suspending  its  use,  at  least  until  the  milk  secreted  by 
it  is  free  from  pus.  In  cases  where  the  nipple  is  cracked  or 
fissured  and  a  secretion  of  pus  takes  place,  this  also  is  a  suffi- 
cient reason  why  nursing  should  be  interdicted  until  the 
trouble  is  cured.  This  can  usually  be  effected  by  the  frequent 
application  of  the  compound  tr.  of  benzoin,  or  tr.  of  calen- 
dula. Washing  the  nipple  frequently  with  a  solution  of  borax 
will  often  prove  serviceable.  Primipara  should  be  instructed 
to  apply  some  astringent  to  their  nipples  daily  during  the  last 
month  or  so  of  their  pregnancy,  in  order  to  harden  them  and 
prepare  them  for  the  application  of  the  child's  mouth  which, 
under  neglect,  is  sometimes  at  first  very  painful.  At  the 
same  time  this  is  done  traction  should  be  made  on  the  nipple 
with  the  fingers  in  cases  where  this  organ,  which  is  so  essential 
to  the  proper  performance  of  the  function,  is  depressed  or 
retracted.  Even  in  bad  cases  of  depression,  a  fair  nipple  can 
be  developed  by  persistent  and  intelligent  effort. 

The  Goodyear  breast-pump,  if  properly  and  persistently  used 
for  a  month  or  more  before  confinement,  will,  by  the  suction 
which  is  brought  to  bear  upon  the  depressed  nipple  often  de- 
velop an  otherwise  useless  organ  into  one  which  may  answer 
every  purpose.  A  common  clay  pipe  with  its  edges  made 
smooth  is  another  expedient  which  is  frequently  resorted  to 
with  success. 

Where  this  matter  has  not  been  attended  to  prior  to  the 
birth  of  the  child,  the  primipara  should  be  encouraged  to  hope 


MENSTRUATION  AND  PREGNANCT.  37 

that  as  the  infant  grows  stronger  its  natural  effort  will  succeed 
after  a  time  in  overcoming  the  defect  and  develop  a  nipple  that 
will  answer  all  necessary  purposes. 

Women  who  have  never  suckled,  become  very  impatient 
and  nervous  when  they  discover  their  inability  to  perform  the 
act  at  once,  and  become  feverish  and  excited,  which  has  a  del- 
eterious effect  upon  the  milk.  Such  women  should  be  assured 
that  in  all  probability,  the  difficulty  will  pass  away  in  a  few 
days  or  a  week,  and  that  their  unremitting  efforts  to  nurse  at 
the  expense  of  rest  and  sleep  are  detrimental  both  to  mother 
and  babe. 

While  waiting  for  the  young  infant  to  gather  sufficient 
strength  to  draw  out  a  serviceable  nipple  the  desired  object  can 
often  be  expedited  by  calling  in  the  service  of  an  older  and 
stronger  nursling,  who  by  its  more  vigorous  efforts  and  greater 
experience  may  be  able  to  seize  the  nipple  and  develop  it.  It 
is  every  way  essential  to  successful  nursing  that  the  mind  of 
the  young  mother  should  be  calm  and  placid.  Anything  which 
creates  apprehension  or  interferes  with  repose  militates  strongly 
against  the  function  of  lactation  and  renders  both  mother  and 
child  ill. 

Menstruation  and  Pregnancy. — There  is  a  diversity  of 
opinion  among  authors  as  to  the  effect  of  menstruation  upon 
the  mother's  milk  and  thence  upon  the  child.  On  the  one 
hand,  it  is  claimed,  that  if  any  disturbance  is  felt  by  the  nurs- 
ing infant,  at  the  first  return  of  the  menstrual  flow,  it  is  ordi- 
narily attended  with  but  little,  if  any  serious  effects,  which  are 
not  only  trifling  in  character,  but  brief  in  duration  ;  that  the  great 
advantages  to  the  child  from  having  the  breast,  especially  to  fall 
back  on  in  case  of  sudden  illness,  far  outweighs  the  disadvantages 
and  dangers.  It  is  also  claimed  that  the  milk  is  so  little  changed 
in  quality  even  during  the  flow  that  its  effect  on  the  child's  nu- 
trition and  growth  is  inappreciable.  On  the  other  hand,  it  is 
stated  on  good  authority  that  in  many  cases  the  indigestion 
which  is  set  up  at  this  time  is  or  may  be  serious ;  that  vomit- 
ing and  diarrhea  are  not  at  all  exceptional,  and  even  more  dan- 
gerous symptoms  are  not  uncommon.  My  own  observation 
leads  me  to  think  that  few  women  can  carry  on  the  two  func- 
tions successfully  at  the  same  time.  I  am  sure  that  this  is  so 
when  the  menstrual  flow  is  excessive  or  unduly  prolonged  ;  or 
again  when  it  is  attended  with  much  pain  and  general  constitu- 
tional disturbance.  Under  these  circumstances  the  nursing 
babe  is  almost  sure  to  suffer  more  or  less  from  some  gastric  dis- 
turbance, which  is  apt  to  continue  until  the  flow  is  over,  or  at 
least  for  a  day  or  two.     It  matters  not  that  chemical  analysis 


38  THE  DISEASES  OF  CHILDREN. 

shows  that,  ordinarily,  the  miik  is  but  Httle  altered  in  its  physi- 
cal composition.  The  fact  that  the  baby  shows  it  in  colic  and 
diarrhea,  feverishness  and  fretting,  is  evidence  enough  that  tem- 
porarily at  least  the  milk  is  a  cause  of  disturbance,  and  I  have 
seen  numerous  cases  where  this  condition  was  noticeable  at 
each  return  of  the  menstrual  epoch. 

Our  plan  of  late  has  been  to  advise  weaning  at  the  second  re- 
turn of  the  menses,  unless  there  was  something  in  the  season 
of  the  year  or  other  good  reason  for  deferring  it  till  a  later 
period.  It  may  be  advisable  in  some  cases,  especially  when 
the  mother's  milk  has  been  agreeing  with  the  child  heretofore, 
to  only  partially  wean  it ;  giving  it  the  breast  in  the  intervals 
between  the  menstrual  periods  and  feeding  by  bottle  during 
the  flow. 

As  to  the  effect  of  pregnancy  on  the  function  of  lactation, 
there  can  be  no  two  opinions.  No  woman  can  nurse  a  babe  at 
the  breast  and  do  justice  to  another  in  her  womb  at  the  same 
time.  One  or  the  other — and  commonly  both — must  inevitably 
suffer.  As  soon  as  pregnancy  takes  place  in  the  nursing  woman 
there  is  a  diversion  of  some  of  the  solid  constituents  of  her 
milk  to  help  in  the  formation  of  the  fetus  in  utero.  Her  milk 
becomes  thinner  and  more  watery  and  the  nursing  babe  begins 
to  decline  in  weight  and  spirits. 

A  prolongation  of  the  function  under  the  circumstances  is 
almost  certain  to  result  in  a  rickety  child. 

It  will  be  a  matter  of  good  fortune  if  it  does  not  result  in  two 
of  them.  Under  certain  circumstances,  such  as  extremely  hot 
weather,  it  may  be  deemed  best  to  postpone  weaning  for  a  few 
weeks ;  but  if  a  competent  wet-nurse  can  be  procured  this  is  far 
preferable  and  far  safer.  No  child  should  be  weaned  in  the 
city  during  the  extreme  heat  of  summer,  no  matter  what  its 
age  or  the  necessities  which  render  the  weaning  expedient. 
All  experience  goes  to  show  that  summer  complaint  and  cholera 
infantum  are  vastly  more  common  during  summer  in  the 
city  than  in  the  country,  and  a  child  just  weaned  is  much 
more  liable  to  these  diseases  than  one  accustomed  to  a  mis- 
cellaneous diet. 

Scantiness  of  Milk  and  Partial  Feeding. — The  exact 
amount  of  nourishment  required  by  a  healthy  infant  in  each 
twenty-four  hours  can  only  be  approximated.  Some  children 
take  a  great  deal  more  than  others  and  some  women  have  a 
much  more  copious  secretion  than  others.  There  is  no  fixed 
rule  by  which  the  quantity  can  be  gauged  or  by  which  we  can 
tell  whether  the  secretion  is  ample  for  the  needs  of  the  infant 
except  that  test  which  we  have  spoken  of  before — the  test  of 


SCANTINESS  OF  MILK.  39 

experience.  If  the  infant  takes  a  proper  amount  of  sleep — if 
it  drops  asleep  habitually  after  nursing  and  has  a  long  nap — if 
its  color  is  normal  and  it  seems  happy  and  contented — if  in 
addition  it  is  perceptibly  growing  in  weight,  it  is  fair  to  pre- 
sume that  the  milk  is  abundant  in  quantity  and  satisfactory  in 
quality.  If,  on  the  other  hand,  the  child  is  restless  and  fretful 
and  soon  exhausts  the  breast  without  being  satisfied  ;  if  it  wants 
to  be  nursing  all  the  time  and  does  not  show  evidences  of 
growth  and  contentment,  the  inference  is  a  just  one  that  the 
milk  is  defective  either  in  quality  or  quantity.  Unless  there 
are  evidences  to  the  contrary,  it  is  fair  to  presume  that  it  is  the 
latter  rather  than  the  former.  The  signs  of  a  good  nurser  will 
be  mentioned  in  the  next  paragraph. 

When  the  deficiency  of  milk  is  manifest,  and  we  have  reason 
to  believe  the  quantity  to  be  good  as  far  as  it  goes,  we  should 
endeavor  to  increase  the  flow  of  milk  by  such  means  as  may  be 
at  our  command.  There  are  two  opposite  conditions  which 
militate  against  the  due  quantity  of  milk  as  well  as  its  quality. 
They  are  the  conditions  of  anemia  and  plethora.  Either  con- 
dition will  disorder  the  secretion  and  yet  both  are  amenable  to 
treatment.  The  anemic  woman  should  have  a  more  generous 
diet,  take  plenty  of  exercise  in  the  open  air  and  by  every  means 
build  up  her  general  health.  The  other  condition,  that  of  hy- 
peremia, is  more  commonly  met  with  in  wet-nurses  who,  by 
reason  of  their  new  vocation,  have  suddenly  risen  from  want  to 
affluence.  A  woman  of  the  poorer  classes,  who  is  admitted  into 
a  well-fed  household  where  plenty  abounds,  is  very  apt  to  grat- 
ify her  appetite  to  the  extent  of  gormandizing.  If  given  all 
she  wants,  she  will  soon  surfeit  herself  and  become  too  plethoric 
for  the  proper  performance  of  her  duties. 

Her  breasts  may  increase  in  size,  but  mainly  from  a  deposi- 
tion of  fat.  The  treatment  of  such  cases  is  too  obvious  for 
comment.  When  a  mother  finds  her  milk  deficient  in  the  first 
few  days  of  lactation,  she  should  be  encouraged  to  persist  in  her 
efforts  to  nurse,  notwithstanding  the  small  amount  of  secretion, 
for  nothing  so  stimulates  the  flow  of  milk  as  suction. 

The  babe  should  be  put  often  to  the  breast,  and  if  it  lacks 
sufficient  strength  to  bring  about  an  abundant  flow,  the  breast 
pump  may  be  employed  as  an  auxiliary,  and  the  milk  thus  ex- 
tracted fed  to  the  infant.  The  use  of  electricity  is  oftentimes 
very  beneficial.  The  Faradic  current  is  the  one  we  have  usually 
employed,  and  the  one  we  regard  as  most  efficacious.  The  fact 
is  now  well  established  by  physiological  experiments  that 
glandular  organs  can  be  made  to  secrete  more  actively  by  the 
stimulus  of  electricity  and  its  clinical  employment  as  a  galac- 
tagogue  affords  ample  proof  of  its  efficacy.     We  have  very  ma- 


40  THE  DISEASES  OF  CHILDREN. 

terially  promoted  the  secretion  in  numerous  cases  and  regard 
it  as  superior  in  general  to  all  other  means. 

In  employing  electricity  for  this  purpose  we  apply  the  posi- 
tive pole — the  sponges  being  well  moistened  with  warm  water 
— to  the  hypogastric  region  just  over  the  solar  plexus,  and  the 
negative  over  the  mamme,  moving  the  electrode  about  con- 
stantly during  the  application.  After  the  current  has  been 
applied  for  from  three  to  five  minutes,  the  poles  may  be  placed 
on  and  around  the  breasts,  so  as  to  direct  it  through  them  from 
side  to  side.  The  current  should  be  as  strong  as  can  be  borne 
without  discomfort. 

In  spite  of  all  our  efforts  we  frequently  fail  to  establish  an 
adequate  secretion  of  milk  to  meet  the  wants  of  the  insatiate 
infant,  and  we  are  confronted  with  the  question  whether  the 
mother,  with  only  a  partial  supply  of  nutriment,  should  con- 
tinue to  nurse  the  child,  giving  it  all  she  is  able,  and  supple- 
ment this  with  artificial  food,  or  abandon  nursing  altogether. 
There  is  a  popular  notion — a  fallacy,  as  we  regard  it — that 
mixed  food  is  not  likely  to  agree  with  the  average  child.  How 
this  prejudice  against  combining  suckling  and  hand-feeding  has 
happened  to  become  so  widespread  is  a  mystery.  It  surely  is 
illogical  and  contrary  to  clinical  experience.  If  human  milk 
and  cow's  milk  fail  to  agree  when  they  commingle  in  the  child's 
stomach  and  create  a  disturbance  there,  it  surely  is  not  the 
mother's  milk  that  is  to  blame,  provided  her  milk  is  healthy, 
and  quantity  is  its  only  fault.  The  cow's  milk  may  disagree,, 
but  rarely  the  mother's.  All  that  the  child  can  get  of  this,  the 
better  ;  it  is  pure  gain.  It  may  be  that  the  child  is  unable  to 
digest  cow's  milk,  or  any  of  the  other  artificial  foods  that  are 
presented  in  the  way  of  substitute  for  the  deficiency,  but  this 
is  all  the  more  reason  why  it  should  have  as  much  mother's 
milk  as  it  can  get ;  for  this  it  can  digest,  and  half  a  loaf  is  better 
than  no  bread. 

The  diet  of  a  nursing  woman  should  be  generous  without 
being  rich.  She  should,  if  her  supply  of  milk  is  at  all  deficient, 
drink  freely  of  cow's  milk  and  good,  nutritious  soups.  Oat- 
meal and  barley  gruels  are  most  excellent  milk-makers,  and 
plenty  of  fluids  should  enter  into  her  dietary.  This  does  not 
mean  that  her  entire  food  should  be  of  the  "  sloppy  "  order,  for 
she  may  eat  with  reasonable  freedom  of  all  that  experience  has 
taught  her  to  regard  as  wholesome.  She  should  avoid  spices 
and  all  forms  of  condiments,  and  such  articles  of  food  and  drink 
as  are  over  stimulating.  She  need  not  abstain  from  acid  fruits,  if 
she  is  fond  of  them,  and  finds  on  trial  that  they  do  not  disturb 
the  baby's  stomach. 

Theoretically,  fruit  acids  ought  not  to  disturb  the  digestion 


SELECTION  OF  A    WET-NURSE.  41 

of  any  nursing  child,  for  in  physiological  digestion,  long  before 
the  acid  which  is  taken  into  the  stomach  of  the  mother  can 
reach  the  milk  glands  through  the  blood,  it  is  changed  into 
alkalies,  and  is  therefore  harmless.  Here  is  another  instance, 
however,  where  practice  turns  its  back  on  precept.  Theory  is 
one  thing,  and  practical  experience  is  quite  another.  In  spite  of 
the  theory  it  is  found  that  these  acids  do  find  their  way  into 
the  milk,  and  gripe  the  baby  whenever  they  are  eaten.  When 
this  is  so,  they  should  be  avoided,  as  well  as  all  other  articles  of 
food  that  produce  colic. 

The  use  of  beer  and  all  fermented  drinks  by  nursing  women 
is  to  be  deprecated.  Their  use  as  promoters  of  lactation 
is  a  delusion  and  a  snare.  Anemic  women  whose  appetite  is 
poor,  may  take  ale  or  porter  once  or  twice  a  day  if  it  agrees, 
but  neither  of  these  should  be  relied  upon  to  the  exclusion  of 
better  things.  These  pallid  mothers  require  a  larger  propor- 
tion of  animal  food  than  women  in  good  general  health  ;  while 
plethoric  women  with  large  appetites  should  restrict  themselves 
to  a  diet  more  farinaceous.  Various  medicines  have  been  em- 
ployed to  increase  the  lacteal  secretion,  but  we  know  of  none 
that  has  any  claims  worthy  of  mention.  What  remedies  are 
taken  should  be  directed  to  improve  the  general  health,  with- 
out regard  to  their  direct  effect  on  the  milk  supply. 

Since  writing  the  above,  our  attention  has  been  called  to  a 
galactagogue  which  seems  to  possess  considerable  merit,  and  in 
the  few  cases  in  which  we  have  used  it,  it  has  certainly  increased 
the  milk  flow  materially. 

We  refer  to  '*  Nutrolactis,"  prepared  by  the  Nutrolactis 
Company,  of  New  York.  It  is  made  from  the  fluid  extracts  of 
the  plants  Galega  Officinalis  and  Galega  Tephrosea — three  parts 
of  the  former  to  one  part  of  the  latter.  It  is  claimed  that  the 
use  of  this  combination  will  greatly  increase  the  quantity  of 
milk  in  all  of  its  essential  elements,  and  maintain  a  sufficient 
flow  during  its  employment. 

The  Selection  of  a  Wet-Nurse. — The  introduction  of 
a  wet-nurse  into  a  family  sometimes  becomes  a  necessary  evil. 
We  speak  advisedly,  for  evil  it  proves  to  be  so  often  in  the 
course  of  a  physician's  experience,  that  he  comes  to  regard  it 
as  more  often  than  otherwise  the  opposite  of  a  divine  blessing. 
Still  the  necessity  frequently  arises,  and  the  responsibility  of 
selection  is  placed  upon  the  physician  in  charge.  I  can  scarcely 
conceive  of  a  duty  more  onerous.  The  class  of  women  who 
offer  themselves  for  this  kind  of  service  is  naturally  open  to 
suspicion  in  every  way.  Self-interest  dictates  the  concealment 
of  all  impediments  and  disabilities.     The  physician  should  re- 


42  THE  DISEASES  OF  CHILDREN. 

gard  it  as  his  bounden  duty  to  subject  them  to  the  most  rigid 
investigation.  If  the  infant  of  the  woman  offering  herself  as  a 
wet-nurse  can  be  seen,  it  will  aid  materially  in  deciding  the 
question  of  her  qualifications.  In  lieu  of  this,  a  certificate  from 
the  doctor  who  attended  her  in  her  confinement,  is  of  much 
value.  Even  references  from  her  employers,  if  she  has  pre- 
viously been  at  service,  may  aid  in  the  investigation.  By  per- 
sonal inspection  and  otherwise  the  exact  state  of  her  health 
and  the  quantity  of  her  milk  should  be  ascertained.  Other 
things  being  equal,  the  best  wet-nurses  are  in  general  appear- 
ance, robust  without  being  corpulent.  They  have  a  clear  skin 
and  a  good  complexion.  Their  breasts  are  full  without  being 
fat  and  tortuous  veins  are  observed  passing  over  them.  Some 
wet-nurses  give  abundance  of  milk  and  that  of  the  best  quality 
whose  breasts  are  small.  These  women  appear  to  secrete  their 
milk  mainly  during  the  time  of  suckling  and  it  is  a  well-estab- 
lished fact  that  the  richest  milk  is  that  which  is  newly  secreted. 
The  longer  the  milk  remains  in  the  breast  the  thinner  it  becomes. 
The  loss  of  milk,  habitually,  by  oozing  is  not  a  good  recom- 
mendation for  a  nurse.  It  generally  indicates  a  relaxed  condi- 
tion of  the  system,  or  a  tendency  to  other  fluxes  of  various 
kinds.  It  is  a  sign  of  weakness  rather  than  of  strength,  and 
bears  no  relation  as  a  rule  to  the  abundance  of  milk  retained. 
In  selecting  a  wet-nurse  attention  should  be  given  to  the  nip- 
ples to  ascertain  if  they  be  well  formed  and  prominent  and 
free  from  excoriations  and  fissures.  The  presence  or  absence 
of  colostrum  should  also  be  determined.  There  should  be  no 
colostrum  after  the  eighth  or  ninth  day  in  good  milk.  If  there 
is  colostrum  present,  as  indicated  by  microscopical  examina- 
tion, it  is  probable  that  there  is  some  fault  in  the  health  or  the 
digestion  of  the  wet-nurse,  and  that  her  milk  may  disagree  with 
the  infant.  A  simple  test  will  determine  approximately  the 
richness  of  the  nurse's  milk.  If  a  quantity  of  it  be  placed  in 
a  test  tube  and  allowed  to  stand  undisturbed  for  a  time,  the 
amount  of  cream  which  rises  to'  the  top  should  be  about  three 
per  cent,  and  the  casein  and  sugar  are  usually  about  the  same 
in  quantity  as  the  cream.  Milk  which  answers  to  this  test  may 
be  regarded  as  up  to  the  usual  average. 

The  milk  of  a  wet-nurse  whose  own  child  is  not  over  six 
months  of  age  will  usually  agree  with  a  new-born  infant.  It  is 
desirable  that  the  wet-nurse  herself  should  be  under  thirty 
years  of  age  rather  than  over;  and  if  she  has  previously  suckled 
and  had  charge  of  infants  it  is  an  added  advantage,  for  such  a 
one  has  gained  at  least  something  in  knowledge  by  her  experi- 
ence. Where  several  candidates  for  the  position  of  wet-nurse 
present  themselves,  preference  should  be  given,  other  things 


DIRECTIONS  FOR  NURSING.  43 

being  equal,  to  the  one  who  is  most  tidy  and  cleanly.  A 
woman  who  is  slovenly  about  her  clothing  is  generally  careless 
about  her  person,  and  in  either  case  her  value  in  the  house- 
hold is  depreciated. 

Directions  for  Nursing. — After  the  mother  has  had  a 
few  hours'  rest  and  has  sufficiently  recovered  from  the  fatigues 
of  labor,  and  after  the  toilet  of  the  new-born  babe  has  been 
duly  made,  it  should  be  applied  to  the  breast.  The  small 
quantity  of  milk  which  it  will  find  there  is  usually  enough  to 
satisfy  its  first  craving,  and  the  act  of  nursing  promotes  further 
secretion.  The  infant  is  so  constituted  that  it  does  not  re- 
quire much  food  during  the  first  few  days  after  birth,  for  other- 
wise nature  would  provide  for  its  needs  sooner  than  she  does. 
In  point  of  fact,  the  full  secretion  is  not  established  as  a  rule 
until  the  third  day,  so  that,  however  often  the  child  is  placed  at 
the  breast,  it  obtains  but  little,  and  that  little  is  colostrum  rather 
than  milk.  The  practice  of  giving  sweetened  water  or  other 
fluids,  on  the  supposition  that  the  child  has  been  starving  in 
utero  and  is  born  hungry,  is  a  great  mistake.  The  seeds  of  in- 
digestion are  liable  to  be  sown  in  this  manner  which  it  may 
take  weeks  to  overcome.  Filling  the  stomach  in  this  way  has, 
moreover,  a  tendency  to  vitiate  the  infant's  appetite  and  pre- 
vent it  from  drawing  upon  the  nipples  with  the  avidity  which  is 
necessary  to  stimulate  a  free  flow  of  milk.  Should  the  infant 
have  nothing  except  what  it  is  able  to  extract  from  the  breast 
before  the  third  day,  no  uneasiness  need  be  felt  on  this  account. 
Its  stomach  will  be  in  much  better  condition  to  receive  its 
legitimate  food  when  it  comes  than  if  upset  in  the  meantime  by 
unsuitable  foods.  Should  the  child,  however,  refuse  to  be  paci- 
fied, and  especially  if  the  third  day  comes  without  any  increase 
of  milk  in  the  mother's  breast,  it  will  be  quite  proper  to  give 
at  intervals  of  two  or  three  hours  a  small  feeding  of  cream  and 
hot  water — half  and  half — sweetened  with  sugar  of  milk.  Cane 
and  beet  sugars  should  never  be  used  for  sweetening  a  baby's 
food  if  milk-sugar  is  obtainable.  It  is  well  to  observe  that  the 
latter  is  not  nearly  so  saccharine  as  the  former,  so  that  a  larger 
quantity  should  be  used. 

As  soon  as  the  mother  finds  herself  in  condition  to  supply 
the  alimentary  needs  of  her  child,  its  education  should  begin. 
It  should  be  taught  the  primary  lesson  of  good  digestion,  viz., 
regularity  of  feeding.  During  its  first  month  it  should  nurse 
about  every  two  hours  during  the  day  and  twice  during  the 
night,  or  about  ten  times  during  each  twenty-four  hours.  The 
stomach  of  the  new  born  holds  but  little,  while  its  digestion  is 
very  active. 


44  THE  DISEASES  OF  CHILDREN. 

After  the  first  month  the  intervals  of  feeding  may  be 
gradually  prolonged  so  that  by  the  fourth  month  they  should 
be  three  hours  during  the  day,  and  by  the  sixth  month  four 
hours  and  once  during  the  night.  By  this  time  the  child  should 
begin  to  take  some  artificial  food — such  as  barley  water  and 
cow's  milk — a  good  way  being  to  alternate  this  with  breast  feed- 
ing. The  practice  which  is  all  too  common  of  putting  the  in- 
fant to  the  breast  every  time  it  cries,  even  though  it  has  just 
been  fed,  is  extremely  pernicious.  It  is  slavery  for  the  mother 
and  a  detriment  to  the  child. 

A  strong  proof  of  the  prevalent  belief  that  every  child  is 
born  into  the  world,  not  only  with  an  immortal  soul,  but  also  a 
modicum  of  the  seeds  of  "  original  sin,"  is  found  in  the  won- 
derful facility  with  which  it  falls  into  bad  habits.  The  more 
these  bad  habits  are  fostered,  the  more  they  will  grow ;  and  in 
due  time  the  mother  will  find,  to  her  sorrow,  a  practical  exem- 
plification of  the  fact  that  "  They  who  sow  to  the  wind  shall 
reap  the  whirlwind." 

The  infant  stomach  must  have  time  to  digest.  It  cannot 
work  continuously  and  work  well.  If  allowed  to  try  the  ex- 
periment anew,  it  will  only  result  in  indigestion,  diarrhea  and 
fretfulness.  Systematic  feeding  at  such  intervals  as  will  give 
the  stomach  time  to  dispose  of  the  preceding  meal  will  best 
subserve  the  interests  of  the  child  and  the  mother  as  well. 

It  is  not  intended  by  this  that  anything  like  mathematical 
exactness  shall  be  observed.  There  are  exceptions  to  all  rules 
and  circumstances  alter  cases.  If  the  infant  is  having  a  quiet 
and  natural  sleep  when  the  time  comes  around  for  nursing, 
common  sense  would  dictate  an  undisturbed  slumber  and  a  post- 
ponement of  nursing  until  it  should  awaken.  It  will  be  wide 
awake  enough  when  its  system  requires  more  nutriment. 

By  the  time  an  infant  reaches  the  age  of  six  or  eight  months, 
and  sometimes  earlier,  the  mother  becomes  more  or  less  fagged, 
even  though  her  menses  have  not  yet  appeared  ;  her  milk  begins 
to  deteriorate  and  lose  something  both  in  the  matter  of 
abundance  and  quality ;  at  the  same  time  the  nutritive  needs 
of  the  infant  become  greater ;  the  teeth  are  beginning  to  come 
to  the  surface,  and  a  greater  amount  of  nourishment  is  now 
more  needed  than  before.  Few  women  are  able  to  carry  on  the 
process  of  lactation  beyond  this  period  and  meet  the  require- 
ments of  growth  and  development  without  the  supplemental 
aid  of  artificial,  or  as  Cheadle  calls  it,  *'  alien  "  food.  It  is  not 
necessary  as  yet,  under  ordinary  circumstances,  if  the  mother  is 
strong  and  experiences  no  exhaustion  from  suckling,  to  wean 
the  infant  abruptly ;  but  it  is  necessary  to  furnish  some  addi- 
tional pabulum  to  meet  the  new  requirements. 


DIRECTIONS  FOR  NURSING.  45 

It  is  better  to  anticipate  this  need  rather  than  to  wait  until 
its  necessity  is  forced  upon  us.  Besides  this,  it  is  better,  as  soon 
as  the  infant  is  of  suitable  age,  to  gradually  accustom  it  to  a 
less  restricted  diet  than  that  of  the  breast.  This  age  varies 
considerably.  With  some  it  may  be  reached  by  five  or  six 
months,  while  with  others  it  may  not  be  reached  before  nine  or 
ten  months.  The  mother's  state  of  health,  the  infant's  physi- 
cal development,  the  time  of  year — various  factors  enter  into 
the  question,  and  in  some  cases  hasten  and  in  others  defer  this 
and  all  other  experiments.  The  addition  of  supplementary 
food,  as  just  advised,  is  deemed  expedient,  partly  as  a  prepara- 
tion for  weaning  entirely,  which  should  rarely  ever  be  post- 
poned beyond  the  end  of  the  first  year.  It  is  never  best  to 
wean  an  infant  during  the  heat  of  summer,  nor  while  ill,  unless 
the  illness  be  caused  presumptively  by  the  mother's  milk. 

As  solid  food  requires  a  greater  development  of  the  digest- 
ive apparatus  to  accomplish  perfect  assimilation  than  liquid, 
the  latter  should  be  given  in  preference  to  the  former,  both 
with  the  breast  milk  and  after  weaning.  Solid  food,  indeed, 
should  not  be  given  until  the  canine  teeth  have  appeared. 
When  they  have  come  the  infant  should  have  sixteen 
teeth,  and  the  peptic  glands  of  the  stomach  be  correspondingly 
developed.  Even  then  it  is  better  that  weaning  should  be 
gradual  rather  than  abrupt.  The  sudden  change  of  food  is  apt 
to  be  followed  by  fretfulness  and  restlessness,  while  the  grad- 
ual change,  to  an  infant  that  for  some  time  has  been  partially 
fed,  is  scarcely  noticeable. 

As  to  the  food  most  desirable  and  safe  to  give  to  an  infant 
after  being  taken  from  the  breast,  we  refer  the  reader  to  the 
next  chapter,  on  Artificial  Food. 


CHAPTER  V. 
FOOD  AND  FEEDING — {Continued.) 

Artificial  Feeding.  —  Cow's  Milk. — When,  for  any 
reason,  artificial  feeding  of  an  infant  becomes  necessary,  the 
contingent  problem  becomes  complicated  and  puzzling.  Theo- 
retically the  matter  is  simple  enough.  The  principles  which 
underlie  the  substitution  of  foreign  or  "  alien  "  food  for  that 
supplied  by  the  human  breast,  are  as  simple  as  the  alphabet. 
The  analysis  of  a  healthy  woman's  milk  shows  exactly  the 
chemical  constituents  of  that  aliment  which  nature  herself  pro- 
vides for  the  due  sustenance  of  the  human  infant,  and  the  rel- 
ative proportion  of  the  elements  which  enter  into  its  normal 
composition.  But,  as  we  have  seen  already,  nature  does  not 
make  allowance  for  those  aberrations  of  functional  power  on  the 
part  of  the  infant,  and  does  not  take  into  consideration  the  fact 
that  infants  are  sometimes  born  with  digestions  so  weak  and 
imperfect  that  even  breast-milk  is  beyond  the  powers  of  assimi- 
lation. There  are  occasional  and  exceptional  cases  in  which  the 
better  the  food  the  worse  it  is  for  the  starveling  infant. 

To  the  uninitiated  this  may  sound  like  a  paradox,  but  just 
such  paradoxes  are  met  with  not  infrequently  by  the  experi- 
enced physician  One  of  the  fundamental  principles  above 
alluded  to  is  that  a  portion  of  the  daily  food  of  an  infant  must 
be  animal.  The  young  of  all  mammalia  require  food  that  has 
previously  been  digested  and  elaborated  by  another  and  an  older 
animal.  Vegetarianism  may  be  well  enough  for  those  that  like  it; 
but  whether  good  or  bad  for  adults,  it  will  not  do  for  infants, 
and  an  exclusive  diet  of  purely  vegetable  food  is  utterly  inade- 
quate to  their  growth  and  sustenance.  One  reason  of  this  is 
that  the  infantile  stomach  is  disproportionately  small  as  com- 
pared with  its  nutritive  needs.  Vegetable  food  is  far  more 
bulky  than  animal,  and  hence  a  much  greater  quantity  must  be 
ingested  to  give  the  same  equivalent  in  nutritive  elements. 
More  than  this,  all  animal  food  is  partly  pre-digested,  and  but 
little  more  needs  to  be  done  after  ingestion  to  render  its  fibrine 
and  albumen  or  casein  fit  for  absorption  and  nutrition. 

This  necessity  for  animal  food,  which,  in  a  breast-fed  infant, 
is  supplied  by  the  mother  or  the  wet-nurse,  is  met  by  the  sub- 
stitution in  other  cases  of  the  milk  of  one  of  the  lower  animals. 
(46) 


ARTIFICIAL  FEEDING.  47 

Singularly  enough,  not  one  of  these  provides  a  food  for  its 
young  which  is  precisely  like  that  of  the  human  female.  /"The 
milk  of  the  ass,  goat,  mare  and  cow,  all  show  differences,  both 
chemically  and  in  the  way  they  behave  when  taken  into  the  in- 
fant's stomach.  Still  these  differences  are  not  very  great,  and 
it  would  seem  as  if  art  ought  to  be  able  to  remove  excesses  and 
supply  deficiencies,  and  make  the  milk  of  ej^er  of  these  animals 
approximate  very  closely,  if  not  entirely>  to  the  average  of  hu- 
man milk.  The  problem,  simple  as  it  seems,  is  not  unattended 
with  difficulties.  It  has  been  found  that  asses'  milk  is  more  like 
human  milk  than  any  other.  But  we  have  no  establishments  in 
this  country,  such  as  are  found  in  London,  where  asses'  milk  is 
provided  on  a  large  scale  for  infantile  needs,  and  other  emergen- 
cies. Goats'  milk,  while  closely  resembling  human  milk,  has  a 
peculiar  odor  which  renders  it  objectionable  ;  and  since  all  milk 
other  than  human  must  be  modified  more  or  less  to  adapt  it  to 
the  human  infant,  it  is  as  easy  to  deal  with  cow's  milk  as  any 
other.  Although  cow's  milk  when  freshly  drawn  differs  in 
essential  respects  from  human,  its  defects  could  be  easily  reme- 
died if  we  could  always  rely  upon  the  freshness  of  our  supply. 
In  the  country,  where  this  can  be  done,  the  problem  is  not  so 
difficult  of  solution.  But  in  cities  and  larger  towns,  where  the 
milk  is  usually  twenty-four,  or  at  least  twelve  hours  old  before 
it  reaches  the  nursery,  it  is  a  very  different  matter.  The  at- 
tempt to  overcome  this  objectionable  feature  by  seeking  a  sup- 
ply of  milk  from  a  stall-fed  animal  is  futile.  No  cow  can  long 
maintain  her  health  and  continue  to  give  good  milk  of  standard 
quality,  that  is  deprived  of  her  accustomed  exercise  and  changed 
in  all  her  regular  habits  of  life.  Human  milk  is  alkaline  in  its 
reaction  ;  so  is  that  of  a  cow  roaming  at  large  in  the  field, 
when  it  is  newly  drawn.  But  the  milk  of  a  cow  that  is  stall-fed 
is  acid  in  its  reaction,  and  soon  falls  below  the  standard  in  the 
matter  of  cream. 

There  is  a  prevalent  notion  among  the  laity,  that  whether  in 
city  or  country,  the  milk  of  one  cow  is  preferable  to  the  mixed 
milk  of  several  cows.  This  is  an  error.  Every  cow's  milk  will 
vary  from  time  to  time  and  every  cow  is  subject  to  many  ail- 
ments which  temporarily  reduce  her  milk  below  the  standard 
in  some  essential  particular.  The  mixed  milk  of  the  dairy 
practically  overcomes  this  difficulty,  and  will  maintain  a  better 
average  than  that  of  any  one  cow.  But  the  great  trouble  with 
dairy  milk,  even  when  served  by  an  honest  dairyman,  is  the 
length  of  time  which  must  necessarily  elapse  between  the  milk- 
ing of  the  cow  and  the  delivery  of  the  milk.  Another  trouble 
is  that  in  spite  of  care  the  milk  will  in  most,  if  not  all  cases,  be 
more  or  less  contaminated  with  filth  and  debris,  and  more  or 


48  THE  DISEASES  OF  CHILDREN. 

less  polluted  either  by  the  hands  of  the  milker,  the  udder  of  the 
cow,  or  by  impurities  gathered  in  the  course  of  transportation. 
Fermentative  changes  are  thus  easily  and  quickly  set  up,  and 
by  the  time  the  milk  is  ready  for  use  these  changes  may  be  pro- 
gressing actively.  On  this  account  the  milk  should  be  strained 
through  a  muslin  cloth  as  soon  as  received,  and  then  boiled  for 
five  minutes  and  bi-carbonate  of  soda  in  the  proportion  of  one 
grain  to  the  ounce  of  milk  should  be  added,  in  addition  to  the 
boiling.  The  milk  should  then  be  placed  in  the  refrigerator 
or  other  cool  place  to  be  used  as  wanted.  Bi-carbonate  of  soda 
is  to  be  preferred  to  lime  water  as  generally  recommended,  be- 
cause the  soda  is  more  assimilable  and  much  more  effectual  as 
an  antacid.  It  seems  illogical  to  take  exception  to  the  water  of 
a  well,  that  shows  a  precipitate  of  lime,  and  refuse  to  use  it 
on  the  general  table,  and  then  go  to  the  drug  store  to  buy  lime- 
water  to  put  in  the  baby's  milk. 

Furthermore,  Sir  W.  Roberts  has  shown  that  ten  grains  of 
bi-carbonate  of  soda  are  equivalent  in  antacid  power  to  six  ounces 
of  lime  water,  and  that  its  effects  on  the  milk  is  to  produce  a 
more  flocculent  curd,  the  very  thing  which  is  so  desirable  in  ren- 
dering cow's  milk  like  that  of  the  mother. 

Peptonized  Milk. — The  principal  reason  why  cow's  milk  is  so 
difficult  of  digestion  by  the  infant  stomach,  is  not,  as  commonly 
supposed,  because  it  contains  more  solid  constituents  than 
human  milk,  especially  casein,  but  because  this  casein  or  curd 
coagulates  into  large  masses  as  soon  as  it  enters  the  stomach 
and  the  gastric  juice  is  not  sufficiently  powerful  to  dissolve 
them.  It  remains  there  an  insoluble  bolus.  To  overcome  this 
trouble,  it  has  been  proposed  to  predigest  the  milk  by  convert- 
ing the  casein  into  soluble  peptone  outside  of  the  stomach. 
This  removes  all  curd  difficulty  and  leaves  the  same  amount  of 
nutriment  in  the  milk  that  was  there  before  it  was  peptonized. 
But  although  peptonized  milk  is  rendered  more  digestible  than 
milk  not  so  treated,  there  are  serious  objections  to  its  continual 
use.  The  chief  of  these  objections  is,  that  it  takes  from  the  stom- 
ach the  proper  exercise  of  its  digestive  function,  and  the  organ 
becomes  enfeebled  thereby.  This  is  a  serious  objection  and 
should  prevent  the  use  of  peptonized  milk  for  any  great  length 
of  time.  In  emergencies,  however,  and  for  the  purpose  of  car- 
rying an  infant  through  an  acute  attack  of  indigestion  from 
other  causes,  it  is  a  valuable  expedient.  Peptonized  milk  has  a 
perceptibly  bitter  flavor  which  makes  some  infants  refuse  it,  but 
this  difficulty  can  usually  be  overcome  by  the  addition  of  a 
larger  quantity  of  sweetening  with  sugar  of  milk  or  by  using 
condensed  milk,  which  is  already  highly  sweetened.  By  using 
peptonizing  powders,  of  which  there  are  numerous  brands  in 


HUMANIZED  AND  BOILED  MILK.  49 

the  market,  the  proportion  of  pepsin  can  be  made  accurate  and 
the  amount  reduced  from  day  to  day  as  it  should  be,  if  con- 
tinued long. 

Humanized  Milk. — Some  infants  appear  to  be  utterly  unable 
to  digest  diluted  cow's  milk,  in  strength  sufficient  to  sustain 
life.  Even  when  diluted  to  the  proportion  of  one  part  milk  to 
three  parts  water,  they  are  griped,  filled  with  flatus  and  are 
constantly  crying  with  pain  and  discomfort.  They  are  restless 
and  suffer  with  diarrhea  as  well  as  with  colic.  They  become 
lean  and  flabby  and  ultimately,  if  no  change  be  made,  die  of 
inanition.  A  successful  device  in  such  cases  is  to  put  the  child 
upon  what  is  called  ''  artificial  human  milk."  This  is  prepared 
by  first  removing  all  the  cream  by  skimming,  after  the  milk 
has  stood  for  a  time.  Then  the  remainder  is  divided  into  two 
equal  portions.  From  one  portion,  all  the  casein  is  removed 
by  rennet,  i.  e.,  converted  into  whey.  The  other  portion  is 
then  mixed  with  the  whey,  and  the  whole  of  the  cream  added. 
This  preparation  will,  therefore,  contain  all  the  lactine,  all  the 
cream,  but  only  half  the  quantity  of  casein.  It  will  thus  be 
nearer  in  composition  to  human  milk  than  cow's  milk,  contain- 
ing sufficient  proteid  and  some  excess  of  fat.  But  it  is  not 
absolutely  identical  with  human  milk,  although  the  proportion 
of  proteid  is  nearly  the  same,  the  curd  is  unchanged  in  nature. 
It  is  still,  as  ascertained  by  experiment,  coarsely  coagulable 
cow's  milk  curd,  although  less  massive  than  that  of  undiluted 
cow's  milk.  The  lactine  is  rather  less,  while  the  fat  is  in  larger 
proportion  than  in  human  milk.  This  is  probably  an  advan- 
tage, and  some  children  who  are  able  to  digest  only  a  limited 
amount  of  cow's  milk  casein  do  remarkably  well  on  it.  Dr. 
Cheadle,  to  whom  I  am  indebted  for  this  formula,  states  that 
humanized  milk  will  not  keep  long.  He  says :  "After  a  time, 
the  cream  separates  with  some  curd  in  great  clots  and  does  not 
easily  mix  again,  I  have  twice  seen  children  dangerously  ill 
from  taking  artificial  human  milk  which  had  been  sent  a  long 
distance  and  had  changed  in  this  way.  If  the  dairy  where  it 
is  manufactured  is  not  within  reasonable  distance,  have  it  made 
freshly  at  home."  When  thus  freshly  made  there  is  no  reason 
to  apprehend  any  danger  from  its  use. 

Boiled  Milk. — The  use  of  boiled  milk  in  diarrhea  has  long 
been  a  practice  among  the  laity,  because  experience  has  taught 
that  when  thus  treated,  the  milk  is  less  laxative  than  when 
given  in  its  raw  state.  The  habitual  use  of  boiled  milk  has 
been  objected  to  by  the  profession,  under  the  mistaken  idea 
that  it  is  rendered  less  digestible  by  boiling.  Dr.  Cheadle's 
experiments  have  demonstrated  that  when  milk  is  boiled  the 
curd  coagulates  in  smaller  masses  than  when  fresh  and  un- 
D.C.— 4 


50  THE  DISEASES  OF  CHILDREN. 

boiled.  He  says,  "  Dilute  acetic  acid,  or  vinegar,  added  ta 
boiled  cow's  milk  which  has  been  allowed  to  grow  cold,  no 
longer  produces  the  massive  coagula,  characteristic  of  fresh 
cow's  milk,  but  smaller  and  lighter  curd  masses,  although  still 
much  larger  and  coarser  than  those  of  human  milk."  There  is 
another  reason  why  all  cow's  milk  used  in  the  city  nursery 
should  be  boiled,  and  that  is  that  boiling  arrests  decomposi- 
tion and  thus  puts  a  stop  to  the  development  of  those  irritant 
products  that  excite  intestinal  action.  We  shall  see  farther  on 
that  the  dilution  of  milk  with  barley  water  or  the  juice  of  one 
of  the  other  cereals  promotes  its  digestion  by  mechanically 
separating  the  casein,  so  that  it  coagulates  under  the  action  of 
the  gastric  juice  in  minuter  flocculi  than  that  boiled  even.  A 
still  further  reason  for  boiling  the  milk  for  city  fed  infants  is 
found  in  the  fact  now  clearly  demonstrated  that  milk  is  one  of 
the  commonest  of  disease  carriers,  and  heating  the  milk  to  a 
temperature  even  of  i8o°  Fahr.,  destroys  contagium  or  ren- 
ders it  harmless.  Boiling  the  milk  entirely  eradicates  all  dan- 
ger from  this  source. 

Boiling  milk  expels  about  three  per  cent,  of  its  gases,  and 
materially  changes  its  odor  and  taste.  As  the  boiled  milk 
cools  on  contact  with  the  air,  a  scum  forms,  which  is  the  albu- 
men coagulable  by  heat,  entangling  in  its  meshes  a  certain 
amount  of  fat.  But  as  cow's  milk  contains  relatively  more 
albumen  (casein)  and  fats  than  human,  the  slight  loss  entailed 
by  boiling  is  immaterial. 

Before  proceeding  further  with  the  discussion  let  us  see  in 
what  particulars  human  milk  and  cow's  milk  differ.  (See  table 
on  opposite  page.) 

It  will  be  seen  that  cow's  milk,  as  compared  with  human 
milk,  contains  less  water  and  sugar  and  more  butter,  casein 
and  salts.  In  order  to  approximate  the  two  kinds  of  milk  as 
nearly  as  possible  we  add  for  an  infant  during  its  first  month 
about  two  parts  water  to  one  part  milk  and  also  a  little  sugar. 
We  thus  bring  the  caseous  element  of  cow's  milk  to  about 
that  of  human  milk  and  the  sugar  is  about  the  same.  In  mak- 
ing this  reduction,  however,  we  have  diminished  other  constit- 
uents below  the  standard  of  human  milk,  so  that  a  larger 
quantity  of  it  must  be  given  than  would  be  required  of  the 
latter  if  we  would  meet  the  requirements  of  the  infant's  sys- 
tem. By  adding  raw  meat  juice  (see  page  6'S)  and  cream,  the 
proteids  and  fats  can  be  increased  as  needed  and  that  in  a  way 
not  to  be  objectionable  even  to  a  stomach  the  most  feeble. 

Another,  and  perhaps  a  simpler  way  to  reduce  the  amount  of 
casein  is  to  let  the  milk  stand  for  an  hour  or  so  after  it  is  de- 
livered, and  then,  to  pour  off  carefully,  the  upper  half,  for  a 


ELEMENTS  IN  VARIOUS  KINDS  OF  MILK. 


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52  THE  DISEASES  OF  CHILDREN. 

very  young  infant,  and  the  upper  two-thirds,  for  an  older  one, 
and  to  do  this  without  disturbing  the  lower  strata  of  milk  into 
which  the  principal  part  of  the  curd  has  gravitated. 

By  resorting  to  this  procedure,  the  upper  portion,  which  is 
the  one  to  be  given  the  infant,  will  be  found  to  have  about  the 
consistence  of  human  milk,  with  the  proportionate  amount  of 
casein  and  fat,  and  does  not  require  the  addition  of  water 
and  but  very  little  sugar. 

When  fresh  cow's  milk  is  reduced  in  its  casein,  as  just  de- 
scribed, till  the  amount  of  its  nitrogenous  constituents  is  on  a  par 
with  human  milk,  it  is  found,  as  we  have  said,  to  be  below 
normal  in  its  fat  and  sugar — the  hydro-carbonates.  This  defect  is 
remedied  in  a  very  ingenious  manner  by  Dr.  Kennedy,  of  New 
York,  who  prepares  an  artificial  food  which  he  calls  Proteinol, 
and  which  can  be  added  to  the  milk  or  other  food,  in  quantities 
to  suit  any  emergency. 

Proteinol  is  made  from  the  entire  egg  (shell  and  all),  which  is 
digested  in  fresh  lemon  juice  ;  to  this  is  added  the  clear  fat  from 
fresh  killed  beef,  saccharated  malt,  and  enough  good  brandy 
to  keep  it  from  undergoing  change. 

Dr.  George  W.  Winterburn's  favorite  food  for  a  healthy 
child  of  a  month  old,  who  is  not  as  yet  affected  with  vomiting 
or  diarrhea,  but  who  is  obliged  to  be  put  on  artificial  food,  is 
as  follows :  One  teaspoonful  of  wheat  flour,  boiled,  baked  and 
grated  as  described  on  page  56;  one  teaspoonful  of  condensed 
milk  (Eagle  or  Anglo-Swiss)  ;  one-half  teaspoonful  of  proteinol, 
and  twenty-four  teaspoonfuls  of  water.  "An  analysis  of  this," 
he  says,  "  and  an  analysis  of  healthy,  normal,  average  human 
milk  for  a  child  of  the  same  age,  yield  exactly  the  same 
results." 

Sterilized  Milk. — What  has  been  said  of  the  advantage  of 
boiling  milk  and  its  increased  digestibility  thereby  is  only  true 
if  the  milk  be  just  brought  to  a  boil  and  then  removed  from 
the  fire — parboiled,  as  it  were.  If  the  boiling  process  be  con- 
tinued for  any  length  of  time,  the  effect  on  the  casein  which  it 
contains  is  precisely  like  that  on  the  albumen  of  ^g<g.  Prolonged 
boiling  condenses  it  into  a  firm  and  indigestible  coagulum 
like  that  of  a  hard-boiled  egg.  This,  of  course,  is  undesirable 
from  every  point  of  view.  Even  an  adult  stomach,  unless  ex- 
ceptionally gifted,  finds  it  difficult  to  dispose  of  either  egg-al- 
bumen or  milk  casein  that  has  been  subjected  to  over-boiling. 

All  of  the  advantages  which  follow  boiling  the  milk,  can  be 
secured  by  heating  it  to  68°  Cor  155°  Fahr.  It  has  been 
found  by  experiment  that  this  degree  of  heat  destroys  any  in- 
jurious germs  or  active  poisons,  which  may  have  found  their 
way  to  it,  either  in  the  cow-yard  or  in  course  of  transportation. 


CEREAL  FOODS  AND  THEIR   USES.  53 

The  taste  of  boiled  milk  is  somewhat  changed  and  rendered 
unpalatable,  which  is  not  the  case  if  it  be  merely  heated  to  the 
temperature  above  indicated.  This  process  of  heating,  but  not 
boiling,  is  called  "  sterilization,"  and  answers  all  the  purposes 
necessary  for  purification  and  preserving  without  any  objec- 
tionable features.  A  simple  means  of  accomplishing  this  ob- 
ject is  thus  described  by  the  United  States  Secretary  of  Agri- 
culture : 

"  The  vessel  containing  the  milk,  which  may  be  the  bottle 
from  which  it  is  to  be  used  or  any  other  suitable  vessel,  is  placed 
inside  of  a  larger  vessel  of  metal,  which  contains  the  water.  If 
a  bottle,  it  is  plugged  with  absorbent  cotton  if  this  is  at  hand, 
or  in  its  absence  other  clean  cotton  will  answer.  A  small  fruit 
jar,  loosely  covered,  may  be  used  instead  of  a  bottle.  The  re- 
quirements are  simply  that  the  interior  vessel  shall  be  raised 
about  half  an  inch  above  the  bottom  of  the  other  and  that  the 
water  shall  reach  nearly  or  quite  as  high  as  the  milk.  The  ap- 
paratus is  then  heated  on  a  range  or  stove  until  the  water 
reaches  a  temperature  of  155°  Fahr.,  when  it  is  removed 
from  the  heat  and  kept  tightly  covered  for  half  an  hour. 
The  milk  bottles  are  then  taken  out  and  kept  in  a  cool  place. 
The  milk  may  be  used  any  time  within  twenty-four  hours.  A 
temperature  of  150°  maintained  for  half  an  hour  is  suffi- 
cient to  destroy  any  germs  likely  to  be  present  in  the  milk,  and 
it  is  found  in  practice  that  raising  the  temperature  to  155° 
and  then  allowing  it  to  stand  in  the  heated  water  for  half 
an  jiour  insures  the  proper  temperature  for  the  required  time. 
The  temperature  should  not  be  raised  above  155°,  other- 
wise the  taste  and  quality  of  the  milk  will  be  impaired. 

"  The  simplest  plan  is  to  take  a  tin  pail  and  invert  a  perforated 
tin  pie-plate  in  the  bottom,  or  have  made  for  it  a  removable 
false  bottom  perforated  with  holes  and  having  legs  half  an  inch 
high,  to  allow  circulation  of  the  water.  The  milk  bottle  is  set 
on  this  false  bottom,  and  sufficient  water  is  put  into  the  pail  to 
reach  the  level  of  the  surface  of  the  milk  in  the  bottle.  A  hole 
may  be  punched  in  the  cover  of  the  pail,  a  cork  inserted,  and 
a  chemical  thermometer  put  through  the  cork,  so  that  the  bulb 
dips  into  the  water.  The  temperature  can  thus  be  watched 
without  removing  the  cover.  If  preferred,  an  ordinary  dairy 
thermometer  may  be  used  and  the  temperature  tested  from 
time  to  time  by  removing  the  lid.  This  is  very  easily  arranged, 
and  is  just  as  satisfactory  as  the  patented  apparatus  sold  for 
the  same  purpose." 

The  Cereal  Foods  and  Their  Uses.  —  The  fact  that 
nature  provides  an  animal  food  for  the  human  infant,  and  the 


54  THE  DISEASES  OF  CHILDREN. 

further  fact  that  all  vegetable  foods  contain  more  or  less  starch, 
which  is  not  found  in  milk,  and  which  does  not,  and  cannot, 
enter  into  the  organism  as  starch — these  facts  are  on  the  face 
of  them  prohibitory,  when  considering  their  availability  as  a 
substitute  for  human  milk.  Physiology  teaches  us  that  before 
starch  can  be  assimilated,  it  must  be  transformed  into  dextrin, 
or  grape  sugar.  It  cannot  take  part  in  the  economy,  until  this 
change  is  effected.  As  starch,  it  is,  when  taken  into  the  blood, 
a  foreign  and  useless  element.  Physiology  teaches  further- 
more that  in  adult  digestion  this  transformation  of  starch  into 
grape  sugar  is  effected  by  the  digestive  juices,  with  which  it 
comes  in  contact  between  the  mouth  and  the  colon.  The  saliva 
begins  the  transformation  and  the  pancreatic  and  the  intestinal 
fluids  perfect  it.  But  the  secretions  of  the  infant  are  every- 
where feeble,  and  metabolic  changes  are  effected  with  difficulty. 

It  is  not  until  the  infant  is  a  year  old  or  more,  and  is  in  pos- 
session of  eight  or  ten  teeth,  that  the  saliva  has  the  power  of 
effectively  operating  on  starch,  and  the  pancreas,  which  is  quite 
diminutive  at  birth,  does  not  reach  its  full  proportionate  size 
until  second  dentition  is  well  advanced.  Digestion  of  starchy 
substances  is  therefore,  prior  to  this  period,  a  matter  of  diffi- 
culty and  oftentimes  an  impossibility.  There  is  a  great  vari- 
ety of  baby  foods  manufactured  by  enterprising  firms,  whose 
object  is  to  present  a  cereal  substitute  for  human  milk,  that 
shall  supply  the  infant's  system  with  all  the  requisites  for  full 
nutrition  in  a  form  adapted  to  its  delicate  powers  of  digestion. 
These  foods  will  be  discussed  further  along.  For  the  present, 
suffice  it  to  say  that  the  grains  mostly  employed  in  their  manu- 
facture are  barley,  oats  and  wheat,  whose  digestibility  ranks  in 
the  order  named.  Where  a  domestic  food  is  desired — that  is  to 
say,  "home  made" — a  very  good  one  is  well-cooked  barley 
added  to  boiled  milk.  The  "prepared  **  or  "  pearled  "  barley, 
is  the  proper  article  to  be  used.  A  tablespoo'nful  of  this 
should  first  be  boiled  in  from  four  to  six  ounces  of  water  for 
about  thirty  minutes  and  then  strained  through  a  linen  cloth. 
For  very  young  infants  the  quantity  of  water  should  be  six 
ounces  and  for  older  ones,  say  from  four  to  six  months,  three 
ounces.  This  decoction  should  then  be  added  to  an  equal 
quantity  of  boiled  and  skimmed  cow's  milk,  together  with  a 
pinch  of  salt  and  a  little  sugar.  If  the  milk  has  not  been  pre- 
viously neutralized,  as  heretofore  directed,  a  few  grains  of  bi-car- 
bonate  of  soda  should  be  added. 

This  preparation  should  be  given  at  a  temperature  of  85°  or 
90°  Fahr,,  and  for  infants  under  six  months  old  should  be  served 
through  a  nursing  bottle  with  a  black  or  brown  rubber  tip. 
The  white  rubber  tips  are  unfit  for  use  on  account  of  the  chem- 


CEREAL  FOODS  AND   THEIR   USES.  55 

icals  used  in  bleaching  them.  The  best  nursing  bottle  is  a 
common  flat  glass  bottle  with  just  enough  rim  around  the  neck 
to  hold  the  tip  securely.  Care  should  be  taken  to  select  a  tip 
with  perforations  large  enough  to  permit  a  free  flow  on  suction, 
but  not  large  enough  for  any  considerable  flow  otherwise. 

To  insure  perfect  cleanliness,  two  bottles  and  corresponding 
tips  should  be  provided,  and  the  ones  not  in  use,  should  be 
kept  in  a  moderately  strong  solution  of  bicarbonate  of  soda — • 
a  teaspoonful  to  a  cup  of  water.  No  patent  nursing  bottle, 
with  a  glass  or  ivory  stem  extending  into  its  interior,  should  be 
employed,  as  it  cannot  be  kept  clean. 

In  some  cases  oatmeal  may  be  beneficially  substituted  for 
barley  in  the  above  decoctions,  especially  where  there  is  a  de- 
cided tendency  to  constipation. 

It  will  be  found  that  barley  water  is  better  borne  by  infants 
with  a  delicate  stomach,  while  oatmeal  is  a  slightly  heartier 
food  and  requires  a  stronger  digestion  to  assimilate  it.  It  must 
be  understood  that  the  real  object  of  adding  any  of  the  cereals 
to  milk  is  not  so  much  to  increase  its  nutritive  properties  nor 
to  add  anything  to  its  tissue-making  elements,  but  to  increase 
the  digestibility  of  the  milk  curd.  It  cannot  be  too  often  re- 
peated that  the  great  trouble  which  infants  encounter  in  digest- 
ing cow's  milk  is  due  to  the  firmness  and  coarseness  of  its 
coagula.  Whatever  combines  with  these  caseous  masses  and 
renders  them  finer  promotes  their  digestion.  Dr.  Jacobi  speaks 
in  very  high  terms  of  gum  arable  for  this  purpose.  He  says: 
"  Looking  for  a  substance,  which,  while  fulfilling  this  object,  is 
absolutely  indifferent,  from  a  chemical  and  physiological  point 
of  view,  it  is  gum  arabic.  Its  decoction,  therefore,  as  it  is  not 
influenced  by  the  digestive  liquids  and  is  not  absorbed,  acts 
mechanically  only.  If  I  meant  to  write  a  eulogy  on  gum  arabic, 
I  should  add,  that  its  unpretending  and  unaggressive  nature 
renders  it  particularly  fit  for  an  addition  to  children's  food, 
when,  in  more  advanced  years  also,  their  irritated  intestines  re- 
quire a  soothing  addition  to  the  necessary  nutriment.  With 
the  casein  of  this  mixture  the  gastric  juice  will  get  into  very 
slow  contact  indeed,  thus  producing  a  looser,  because  a  more 
gradual  and  interrupted  coagulation,  on  which  the  digestive 
liquids  and  the  peristaltic  motion  of  the  stomach  have  a  better 
opportunity  to  exert  their  influence."  He  directs  that  a  small 
quantity  of  this  thin  and  transparent  mucilage  be  added  to 
boiled  cow's  milk,  which  has  been  skimmed  and  to  which  has 
been,  or  should  be,  added  the  proper  quantity  of  sugar,  salt  and 
soda.  We  have  had  no  experience  with  this  ourselves,  but 
the  authority  of  Dr.  Jacobi  is  ample  evidence  of  its  utility. 

Instead  of  gum  arabic,  Messrs.  Meigs  and  Pepper  use  gelatin 


56  THE  DISEASES  OF  CHILDREN. 

by  preference,  and  their  formula  is  indorsed  by  other  high  au- 
thorities. We  have  ourselves  found  it  very  serviceable  in  cases 
where  other  foods  have  failed  and  we  can  surely  give  it  credit 
for  saving  one  infant's  life  where  previously  we  had  tried  nearly 
every  other  preparation  without  success. 

The  length  of  the  formula,  and  the  necessity  of  extreme 
accuracy  in  measuring  its  component  parts,  renders  it  objection- 
able, for  few  mothers  or  nurses  are  willing  to  go  to  the  requi- 
site trouble  or  are  too  careless  to  make  its  preparation  success- 
ful. The  author's  formula  is  as  follows :  Dissolve  a  small 
quantity  of  prepared  gelatin  or  Russian  isinglass  in  water  to 
which  is  added  milk,  cream  and  a  little  arrowroot,  or  any  other 
farinaceous  substance  that  may  be  preferred.  A  scruple  of  the 
gelatin  (or  a  piece  two  inches  square  of  the  flat  cake  in  which 
it  is  sold)  is  soaked  for  a  short  time  in  cold  water,  and  then 
boiled  in  half  a  pint  of  water  until  it  dissolves — about  ten  or 
fifteen  minutes.  To  this  is  added,  with  constant  stirring,  and 
just  at  the  termination  of  boiling,  the  milk  and  arrowroot,  the 
latter  being  previously  mixed  into  a  paste,  with  a  little  cold 
water.  After  the  addition  of  the  milk  and  arrowroot,  and  just 
before  the  removal  from  the  fire,  the  cream  is  poured  in,  and  a 
moderate  quantity  of  loaf  sugar  added.  The  proportions  of 
milk,  cream  and  arrowroot,  must  depend  on  the  age  and  digest- 
ive power  of  the  child.  For  a  healthy  infant  within  the  month, 
we  usually  direct  from  three  to  four  ounces  of  milk,  half  an 
ounce  to  an  ounce  of  cream,  and  a  teaspoonful  of  arrowroot  to 
a  half  pint  of  water.  For  older  children,  the  quantity  of  milk 
and  cream  should  be  gradually  increased  to  a  half  or  two-thirds 
milk,  and  from  one  to  two  ounces  of  cream.  We  seldom  in- 
crease the  quantity  of  gelatin  or  arrowroot. 

This  food  is  especially  recommended  for  infants  suffering 
with  diarrhea,  colic  and  vomiting,  and  who  cannot  retain  milk 
and  water  or  cream  and  water. 

Wheat  flour  may  be  used  for  this  same  purpose,  and,  when 
properly  prepared,  makes  an  admirable  baby  food,  as  we  have 
often  demonstrated  in  our  personal  experience.  A  pound  or 
two  of  ordinary  wheat  flour  is  placed  in  a  muslin  bag,  and 
boiled  for  four  or  five  hours  in  water  sufficient  to  cover  it — the 
longer  the  better;  it  should  then,  without  removing  the  bag, 
and  after  being  drained  dry,  be  placed  in  an  oven  and  baked 
into  a  hard  lump.  When  thoroughly  baked  through,  the  mus- 
lin covering  should  be  removed  and  the  ball  grated  as  wanted 
into  flour.  This  flour  may  now  be  added  to  the  boiled  milk  in 
quantities  according  to  the  age  of  the  infant. 

Some  years  ago.  Dr.  Churchill,  of  Dublin,  suggested  a  food 
made  out  of  stale  bread,  which  he  called  bread  jelly,  and  which 


COMMERCIAL  BABT  FOODS.  57 

is  admirably  adapted  to  educate  a  child's  stomach  up  to  a  point 
where  it  can  digest  cow's  milk.  He  prefers  bread  made  out  of 
"  seconds "  flour,  as  this  is  richer  in  proteid  and  phosphates 
than  that  made  from  the  finer  flours.  A  thick  slice  of  this 
bread — about  four  ounces — two  or  three  days  old,  is  placed  in 
a  basin  of  cold  water  and  allowed  to  soak  for  six  or  eight 
hours.  It  is  then  taken  out,  and  all  the  water  squeezed  out  of 
it.  The  object  of  this  first  soaking  is  to  clear  away  the  lactic 
acid  formed  in  fermentation,  and  all  other  deleterious  matters. 
The  pulp  is  then  placed  in  a  pint  of  fresh  water,  and  gently 
boiled  for  an  hour  and  a  half.  The  object  of  this  prolonged 
boiling  is  to  thoroughly  break  up  the  starch  corpuscles,  and  to 
promote  the  change  of  starch  into  dextrin  and  grape  sugar. 
The  thick  gruel  thus  made  is  strained,  rubbed  through  a  fine 
hair  sieve,  and  allowed  to  grow  cold,  when  it  forms  a  fine, 
smooth,  jelly-like  mass.  This  should  be  prepared  freshly  each 
night  and  morning,  for  it  will  not  keep  long.  Enough  of  the 
jelly  is  then  mixed  with  warm  water,  previously  boiled,  to 
make  a  food  of  the  consistence  of  thin  cream,  so  as  to  pass 
readily  through  a  nursing  bottle.  This  means  about  one  full 
tablespoonful  to  eight  ounces  of  water.  A  little  white  sugar 
may  be  added.  This  is  very  weak  food  and  wanting  in  almost 
every  element  of  full  nutrition.  It  is,  however,  easily  brought 
up  to  a  high  nutritive  standard  by  adding  some  animal  element, 
such  as  boiled  milk,  if  milk  is  tolerated,  and  if  not,  by  adding 
instead  raw-meat  juice  and  cream,  the  latter  to  supply  its  nota- 
ble lack  of  fat.  There  may  be  added  to  each  bottle  as  needed 
in  the  proportion  of  four  to  six  teaspoonfuls  of  raw-meat  juice 
and  two  teaspoonfuls  of  cream.  Care  should  be  taken  that 
everything  entering  into  this  concoction  should  be  fresh,  or 
serious  trouble  may  follow.  Raw  meat  is  especially  liable  to 
undergo  decomposition. 

The  Commercial  Baby  Foods. — The  care  necessary  to 
properly  prepare  a  domestic  infantile  food,  and  the  ignorance 
and  inexperience  of  both  mothers  and  nurses  are  so  widespread, 
that  numerous  efforts  have  been  made  to  meet  the  wants  of  uni- 
versal babyhood  by  manufacturing  these  foods  on  a  large  scale 
and  placing  them  on  a  stable  and  satisfactory  commercial  basis. 
Many  physicians  object  to  these  preparations  on  various 
grounds,  and  insist  that  the  home  product  is  every  way  prefer- 
able. We  cannot  agree  with  this  idea.  Because  an  article  of 
wide  consumption  is  made  a  matter  of  merchandise,  it  certainly 
does  not  follow  that  its  preparation  is  lacking  in  uniformity,  or 
that  less  care  is  taken  in  the  making  than  otherwise.  On  the 
other  hand,  the  manufacturers  have  the  strongest  incentives  in 


58 


THE  DISEASES  OF  CHILDREN. 


the  world  to  produce  not  only  the  best  food  that  science  can 
devise,  but  to  maintain  the  integrity  of  its  standard  of  excel- 
lence. They  are  necessarily  provided  with  machinery  and 
appliances  for  its  manufacture,  and  experts  to  superintend 
every  step  of  its  evolution.  They  have  experienced  buyers 
to  select  the  materials  which  enter  into  its  composition,  and 
means  at  tl]eir  command  to  get  the  best  the  markets  afford. 
The  rivalry  between  the  different  foods  for  supremacy,  is 
alone  sufficient  to  insure  uniformity  of  grade  and  perfection 
of  output. 

Their  attention  is  not  diverted  every  few  moments  from  the 
work  in  hand  to  something  entirely  foreign.  They  are  not  dis- 
tracted at  a  critical  moment  by  a  crying  baby,  or  wearied  by 
night-vigils  into  forgetfulness  of  formula.  It  is  their  sole  busi- 
ness to  bring  about  the  best  results,  and  if  their  advertisements 
are  sometimes  exaggerated  in  statement,  it  is  the  business  and 
the  duty  of  the  physician  to  inform  himself  of  the  true  merits 
of  the  case  and  to  act  accordingly.  It  is  unreasonable  to  sup- 
pose that  all  of  the  patent  foods  are  of  equal  value,  and  equally 
absurd  to  regard  them  as  devoid  of  merit  or  a  fraud  upon  the 
public. 

For  convenience  of  comparison  and  in  order  to  form  an  intel- 
ligent idea  of  the  relative  nutritive  value  of  these  foods.  Pro- 
fessor Leeds,  of  Stevens  Institute,  has  made  a  classified  analysis 
of  the  principal  ones  used  in  this  country,  dividing  them  into 
three  classes  as  follows : 

Farinaceous  foods,  viz.,  Imperial  Granum,  Ridge's  Food  and 
various  "wheat  foods"  and  "barley  foods;"  the  so-called 
Liebig  foods,  viz.,  Mellin's,  Horlick's  and  Hawley's ;  milk 
foods,  viz.,  Nestl^'s,  Gerber's  and  the  condensed  milks. 

Farinaceous  Foods, 


1. 

Blair's 
wheat 
food. 

2. 

Hubbell's 

wheat 

food. 

3. 
Imperial 
granum. 

4. 

Ridge's 

food. 

5. 
"A.B.C." 

Cereal 
milk. 

6. 
Robin- 
son's pat. 
barlej-. 

Water 

9-85 

1  75 
1-71 

64  80 

1369 

716 

2  94 
106 

7-78 
041 

4  87 
67  60 
1429 
1013 

Undet'r'd 
I    00 

.';"49 

lOI 

Trace. 

Trace. 

78-9.3 
356 

10-51 
0!;o 
I  i6 

923 
0  63 
2 '40 
2  "20 
7796 

.S»9 
9   24 

0  60 

933 
I  01 
460 

58  42 

20  00 

II  08 

I  16 

lO'IO 

Fat    

097 

Grape  sugar 

30S 

Cane  sugar 

090 

Starch  

77  76 

Soluble  carbohydrates 

Albuminoids 

Gum,  cellulose,  etc. .  . 
Ash 

411 
.S13 
I  93 
I  93 

COMMERCIAL  BABT  FOODS. 
LiEBiG  Foods. 


59 


Water 

Fat 

Grape  sugar 

Cane  sugar 

Starch  

Soluble  carbohydrates 

Albuminoids 

Gum,  cellulose,  etc.  . 
Ash 


Keas- 

bev  and 

Savory 

Baby    sup 

Mellin's. 

Hawley 's 

Matti- 
son's. 

and 
Moore's. 

No.  1, 

5  oo 

6  60 

27  95 

834 

5  "54 

015 

061 

None, 

0   40 

I    28 

44-69 

40  57 

36-75 

2041 

2*20 

3  51 

344 

758 

908 

11-70 

None. 

10  97 

None. 

36  36 

61-99 

85  44 

76  54 

71  50 

44  83 

14  35 

5  95 

538 

None. 

9  63 
0-44 

975 
7-09 

1-89 

I  50 

093 

089 

Undet'r'd 

Baby    sup 
No.  2. 


11-48 
0-62 
2-44 
2   48 

51  95 

22  79 

7-92 

524 
I  59 


Milk  Foods. 


Nestl6's 

Anglo- 
Swiss. 

Gerber's 

American- 
Swiss. 

Water 

4-72 
I   91 
6  92 

32  93 

40-10 

44-88 

823 

I  59 

6  54 

272 

23  29 
21  -40 

34 '55 

46  43 

10 -26 

I  20 

6-78 

2-21 

6-06 

30    50 

3848 

44-76 

956 
I-2I 

568 

6-8i 

Fat 

Grape  sugar  and  milk  sugar . .  . 
Cane  sugar 

5-78 

36  43 
3085 

45  "35 
10-54 

I  "21 

Starch  

Soluble  carbohydrates 

Albuminoids 

Ash 

It  will  be  seen  at  a  glance  that  all  of  the  farinaceous  foods, 
of  which  Imperial  Granum  may  be  taken  as  the  type,  and  the 
"  milk  foods,"  of  which  Nestl^'s  is  the  best  representative,  the 
starch  is  unchanged,  and  this  fact  renders  all  of  this  class  of  foods 
unfit  for  very  young  infants  or  those  with  feeble  powers  of  di- 
gestion. For  infants  of  strong  digestive  powers,  however,  and 
for  those  in  whom  age  has  developed  the  peptic  juices  to  an 
adequate  extent,  these  foods  are  valuable  and  reasonably  reli- 
able. The  farinaceous  foods  are  notably  lacking  in  fats,  but 
are  sufficiently  rich  in  albuminoids.  The  want  of  fat  and  also 
of  sugar  should  be  corrected  in  administering  these  foods. 

The  other  class  of  foods  is  much  better  adapted  to  very 
young  infants,  for  the  reason  that  in  the  preparation  of  them 
the  starch  which  they  contain  is  to  a  greater  or  less  extent  con- 
verted into  dextrin  or  maltose,  and  their  digestibility  thereby 
greatly  facilitated. 

The  maltose  or  grape  sugar  is  the  ultimate  end  which  all 


60  THE  DISEASES  OF  CHILDREN. 

Starch  must  reach  before  it  can  be  assimilated,  and  it  is  this 
transformation  of  starch  into  sugar  that  most  troubles  the 
young  infant,  in  its  attempt  to  digest  artificial  foods.  This 
food  was  suggested  by  Liebig  many  years  ago,  and  consists 
mainly  in  mixing  malted  barley  meal  with  wheaten  flour,  and 
adding  an  alkali,  either  potash  or  soda.  Under  a  certain  amount 
of  heat  the  diastase  of  the  malt  acts  on  the  wheaten  flour  and 
changes  it  into  dextrin,  then  into  maltose  and  then  into  grape 
sugar.  This  is  in  strict  accord  with  physiological  requirements. 
The  process  of  converting  the  starch  into  grape  sugar  artificially 
is  not  weakening  or  demoralizing  to  the  infant's  stomach,  since 
the  diastase  of  the  malt  only  does  for  the  child  what  the  mother 
herself  does,  viz.:  converts  starches  and  sugars  into  lactin  be- 
fore they  are  supplied  to  the  child  in  the  mother's  milk. 

The  best  representative  of  this  class  of  foods  is  that  known 
as  Mellin's,  and  this  we  have  used  in  our  practice  for  some 
twenty  years  with  unabated  satisfaction.  Mixed  with  a  due 
proportion  of  boiled  (sterilized)  cow's  milk  this  food  has  met 
the  requirements  of  more  infants  than  any  other  food  with 
which  we  are  acquainted. 

Mellin's  food  possesses  one  great  advantage  over  other  arti- 
ficial food  preparations.  By  adding  it  to  milk  in  varying  pro- 
portions the  alvine  evacuations  can  generally  be  regulated  with 
great  nicety.  When  the  bowels  are  too  loose  more  milk  should  be 
added,  and  when  there  is  a  tendency  to  constipation  this  can  be 
remedied  by  lessening  the  quantity  of  milk  and  giving  the  food 
nearly  or  quite  clear. 

Meat  Preparations. — There  seems  to  be  a  great  diversity 
of  opinion  upon  the  nutritive  properties  of  the  various  patent 
meat  extracts,  beef  essences  and  juices,  with  which  our  mar- 
kets are  flooded.  The  manufacturers  and  vendors  of  these  prod- 
ucts are  more  actuated  by  a  desire  to  utilize  in  a  profitable 
way  the  waste  materials  of  the  stock  yards  than  to  meet  a  liv- 
ing demand  in  a  scientific  way.  The  weight  of  authority  and 
of  clinical  experience  seems  to  be  against  them.  The  action 
of  heat  to  which  they  are  subjected  in  course  of  preparation 
coagulates  the  albumen  in  which  they  are  none  too  rich,  and 
furnishes  too  large  an  amount  of  extractives  of  low  nutritive 
value.  Beef  tea,  however  made,  is  a  very  poor  food  for  chil- 
dren and  should  never,  for  any  great  length  of  time,  be  de- 
pended upon  alone.  Its  laxative  character  prohibits  it  in 
diarrhea.     The  same  may  be  said  of  veal,  and  chicken  broth. 

Raw-meat  juice  is,  however,  of  great  value,  and  may  be  used 
as  a  substitute  for  the  casein  of  cow's  milk.  In  sickness,  when 
but  little  food  is  tolerated  by  the  stomach,  raw-meat  juice  can 


GAVAGE  (FORCED  FEEDING).  61 

be  given  in  small  quantities  with  great  benefit.  The  best  way  to 
prepare  this  is  to  get  a  pound  of  the  round  of  beef  and  have  it 
ground  through  a  machine.  After  being  heated  over  a  quick 
fire,  the  juice  should  be  squeezed  out  with  a  strongly  made 
lemon  squeezer.  A  good  juicy  piece  of  beef  ought  to  yield 
nearly  an  ounce  and  a  half  of  juice  to  the  pound  of  meat. 
Another  method  of  securing  the  same  result  is  to  place  a  thick 
piece  of  raw  beef  in  a  proper  receptacle  over  a  hot  fire  for  a 
few  moments  and  then  press  out  the  juice  with  a  potato  masher. 
The  amount  of  juice  yielded  in  this  way  is  very  much  less  than 
by  the  previous  method.  The  red,  platter  gravy,  which  ex- 
udes when  a  piece  of  roast  beef  is  cut,  can  also  be  made  avail- 
able. The  juice  of  raw  or  nearly  raw  meat  (beef),  however  it 
mayjDC  secured,  can  be  added  to  milk  or  to  cream,  and  is  a 
very  valuable  addition  thereto.  There  is  nothing  more  digest- 
ible and  nothing  more  nutritive. 

Gavage  (Forced  Feeding). — As  a  means  of  controlling 
obstinate  vomiting  in  the  acute,  wasting  diseases  of  infancy 
and  childhood.  Dr.  L.  Emmett  Holt  has  recently  suggested  the 
employment  of  gavage.  The  process  of  using  is  simple  and 
worthy  of  consideration  in  cases  where  ordinary  feeding  has 
proven  unsatisfactory.     Dr.  Holt  says  :  * 

"  During  the  past  two  years  gavage  has  been  in  daily  use  in 
three  institutions  with  which  I  am  connected,  the  Babies*  Hos- 
pital, the  Nursery  and  Child's  Hospital,  and  the  New  York 
Infant  Asylum.  Our  experience  has  now  extended  to  obser- 
vations upon  upward  of  four  hundred  cases,  in  most  of  which 
gavage  has  been  repeated  many  times.  It  has  been  tried  in 
almost  every  variety  of  acute  disease  in  infants  and  small  chil- 
dren, and  has  won  its  place  as  one  of  the  most  valuable  of  our 
therapeutic  measures  at  this  time  of  life. 

"  The  technique  of  gavage  is  very  simple.  The  ordinary  ap- 
paratus used  for  stomach-washing  is  all  that  is  required,  viz.,  a 
funnel,  eighteen  inches  of  rubber  tubing,  a  soft  rubber  catheter, 
and  a  few  inches  of  glass  tubing  for  connection.  The  catheter 
should  have  a  double  eye.  No.  14,  American  scale,  is  the  best 
size  for  infants  under  six  months,  and  about  No.  17  for  older 
children.  A  four-ounce  funnel  is  large  enough  for  infants,  while 
for  older  children  it  is  an  advantage  to  use  one  holding  six  or 
eight  ounces.  The  child  is  placed  flat  upon  the  back  in  its  crib, 
and  the  head  steadied  by  an  assistant.  The  tongue  is  depressed 
with  the  left  forefinger,  and  the  catheter,  previously  oiled,  is 
pushed  rapidly  down  the  pharynx  until  nine  or  ten  inches  have 


♦New  York  Medical  Record,  April  28, 1894. 


62  THE  DISEASES  OF  CHILDREN. 

passed  the  lips.  The  funnel  is  now  raised  high  in  the  air  for  a 
few  moments  to  allow  gas  from  the  stomach  to  escape.  The 
food  is  poured  into  the  funnel  and  rapidly  runs  into  the  stom- 
ach. As  the  last  of  the  food  leaves  the  funnel  the  catheter  is 
tightly  pinched  and  quickly  withdrawn.  This  last  step  is  an 
important  one,  in  order  to  prevent  trickling  of  food  in  the 
pharynx,  which  may  provoke  vomiting.  Sometimes  the  food 
remains  in  the  funnel,  and  will  not  run  into  the  stomach.  This 
is  not  ordinarily  from  blocking  the  eye  of  the  catheter  by  mu- 
cus, but  from  gas  in  the  tube.  In  a  few  moments  this  gener- 
ally rises  to  the  surface  of  the  liquid,  and  then  the  food  flows 
readily.  If  regurgitation  of  the  food  takes  place,  it  is  generally 
immediately  after  withdrawing  the  tube.  In  many  cases  it  may 
be  prevented  by  allowing  the  gas  to  escape  from  the  stomach 
before  putting  the  food  in,  and  in  others  by  holding  the  jaws 
separated  for  a  few  moments  after  the  catheter  has  been  with- 
drawn. 

"  In  young  infants  no  gag  is  required,  but  in  older  children  one 
is  quite  necessary,  since  otherwise  they  may  bite  the  catheter 
in  two.  Where  a  gag  is  needed  the  ordinary  one  accompany- 
ing intubation  sets  will  answer  the  purpose.  Two  assistants 
are  usually  required  to  feed  an  older  child.  It  is  important 
that  the  child  should  be  held  flat  upon  its  back. 

"  The  time  consumed  in  feeding  by  gavage  is  from  ten  to  thirty 
seconds.  In  infants  this  is  very  easily  done.  In  the  institu- 
tions referred  to  all  the  nurses  have  been  taught  to  do  it,  and 
they  learn  with  very  little  experience  to  do  it  very  quickly. 

"  The  uses  of  gavage  may  be  briefly  stated  as  follows : 

"I.  In  premature  infants  its  value  has  been  well  established 
on  the  continent  of  Europe,  in  connection  with  the  use  of  the 
incubator.  As  yet  we  have  had  but  little  experience  with  it  in 
this  country. 

"2.  It  is  useful  in  controlling  persistent  vomiting  in  very  young 
infants,  where  the  vomiting  occurs  partly  from  habit  and  partly 
from  exaggerated  pharyngeal  reflex.  Dr.  Kerley's  published 
paper  established  this  point  conclusively,  and  subsequent  ex- 
perience has  confirmed  his  observations.  Dr.  R.  B.  Kimball, 
attending  physician  to  the  Summer  Branch  of  the  Babies'  Hos- 
pital, is  soon  to  publish  a  large  number  of  cases  treated  in  the 
summer  of  1893,  also  confirmatory  of  this  point.  I  will  not 
enlarge  upon  it. 

"3.  In  acute  diseases,  where  for  any  reason  children  refuse  all 
food,  or  struggle  violently  against  everything  that  is  offered 
them.  In  very  many  cases  of  severe  illness  in  children  from 
two  to  five  years  of  age,  the  point  is  reached,  after  four  or  five 
days  have  passed,  when  the  child  absolutely  refuses  to  take  any- 


GAVAGB  (^FORCED  FEEDING).  68 

thing,  and  nothing  is  gotten  down  excepting  by  holding  the 
nose.  This  is,  to  my  mind,  one  of  the  most  promising  fields 
for  the  application  of  gavage.  In  very  severe  cases  of  scarlet 
fever,  diphtheria,  broncho-pneumonia,  typhoid,  and  empyema 
just  this  necessity  is  felt. 

"4.  In  serious  brain  disease,  where  the  patient  cannot  be  fed 
by  ordinary  means.  This  may  occur  in  tubercular  meningitis, 
chronic  meningitis,  and  in  many  other  diseases  where  delirium 
or  coma  is  a  symptom.  Life  is  not  only  prolonged,  but  exist- 
ence made  more  tolerable,  and  the  patient  is  much  more  easily 
cared  for  by  the  attendants. 

"A  few  illustrative  cases  will  serve  as  types  of  many :  A  child, 
aged  three,  with  chronic  meningitis,  was  fed  for  six  weeks  by 
gavage ;  by  no  other  means  could  anything  be  gotten  down 
excepting  by  the  expenditure  of  a  great  deal  of  time,  strug- 
gling, and  holding  the  nose. 

"A  child,  aged  two,  with  empyema  and  very  marked  asthenic 
symptoms,  after  two  weeks'  illness  absolutely  refused  every- 
thing in  the  way  of  nourishment,  and  was  in  danger  of  dying 
from  inanition.  For  two  weeks  all  food  was  given  by  gavage, 
at  the  end  of  which  time  the  child  was  able  and  willing  to  drink 
its  milk  from  a  cup,  and  take  stimulants  without  difficulty. 

"A  private  patient,  aged  twenty  months,  with  double  pneu- 
monia and  very  marked  prostration,  had  reached  the  point,  by 
the  tenth  day,  when  almost  nothing  could  be  done  in  the  way 
of  nutrition.  After  gavage  for  two  days  the  temperature  grad- 
ually fell,  the  patient  was  able  to  take  food  naturally,  and 
made  an  excellent  recovery. 

"  In  a  recent  case  of  tubercular  meningitis  seen  in  consultation 
in  private  practice — the  case  was  hopeless  for  five  days  before 
death — all  the  food  was  given  by  gavage.  After  the  case 
closed,  the  attending  physician  said,  '  You  have  no  idea  what 
a  comfort  the  gavage  was  to  the  family.'  This  was  especially 
noticeable  after  the  struggles  to  give  food  which  had  preceded 
its  use. 

"A  recent  case  of  diphtheria  in  private  practice  in  a  little  girl 
aged  five  affords  a  striking  illustration  of  the  benefit  of  this 
means  of  treatment.  The  patient  was  delirious,  profoundly 
septic,  temperature  105°  Fahr.  and  over  for  a  week ;  pharynx, 
tonsils,  uvula,  palate,  aud  part  of  the  mucous  membrane  of  the 
mouth  covered  by  pseudo-membrane.  In  the  words  of  Dr. 
O'Dwyer,  who  saw  the  case, '  the  symptoms  were  about  as  bad  as 
they  could  be.'  After  the  fifth  day,  to  give  either  food  or  stimu- 
lants by  ordinary  means  was  absolutely  impossible.  She  was  be- 
ing worn  out  with  the  constant  teasing  and  forcing.  Even  at  the 
risk  of  heart  failure  three  nurses  held  her  while  I  employed  gav- 


64  THE  DISEASES  OF  CHILDREN. 

age  for  the  first  time.  Not  more  than  three  ounces  of  food  had 
been  gotten  down  in  the  course  of  the  previous  twelve  hours. 
Four  ounces  of  food  and  one  ounce  of  brandy  with  digitalis 
were  given  without  diflficulty,  and  with  but  little  more  disturb- 
ance than  was  necessary  to  make  the  child  swallow  a  table- 
spoonful.  From  this  time  on  gavage  was  practiced  regularly 
every  six  hours ;  the  amount  of  food  was  gradually  increased 
until  eight  ounces  at  a  time  were  given  at  once.  This  was  kept 
up  for  a  week ;  not  once  was  the  food  regurgitated,  and  the 
case  made  a  complete  recovery.  In  my  own  opinion  the  life 
of  the  patient  was  saved  by  this  means. 

"  To  cite  further  cases  is  unnecessary;  enough  has  already  been 
said  to  show  that  gavage  is  easy,  simple,  and  free  from  danger, 
and  a  very  great  resource  in  these  very  difificult  cases. 

"  In  the  adult  when  food  is  refused  by  the  stomach  we  may 
have  recourse  to  the  rectal  alimentation ;  but  in  little  children 
this  is  extremely  unsatisfactory,  and  in  most  cases  is  an  entire 
failure.  As  compared  with  holding  the  nose,  and  forcing  the 
child  to  swallow,  anyone  who  has  seen  the  two  things  done  will, 
I  think,  have  little  difficulty  in  deciding  which  is  easier. 

"  In  most  of  the  cases  to  which  I  have  referred  the  food  given 
has  been  completely  peptonized  milk,  diluted  according  to  the 
age  of  the  child ;  but  for  infants  our  hospital  milk  and  cream 
mixture  in  proportions  suitable  to  the  child's  age.  Stimulants, 
medicine,  everything  that  is  to  be  given  may  be  poured  in  at 
once. 

"  In  older  children,  where  six  or  eight  ounces  at  a  time  are 
given,  gavage  need  not  be  repeated  more  than  once  in  five  or  six 
hours.  In  infants  the  intervals  should  be  one  hour  longer  than 
the  customary  interval  of  feeding. 

"  Stomach  washing  is  required  in  conjunction  with  gavage  in 
most  cases  in  infants;  once  at  least  every  day  the  stomach 
should  be  washed  before  feeding. 

"  In  conclusion  I  can  only  say  to  those  who  are  unfamiliar 
with  this  therapeutic  measure  that  a  careful  trial  will  convince 
anyone  of  its  very  great  value." 

RECAPITULATION. 

1.  Human  milk  is  the  only  natural  food  for  human  infants, 
all  other  foods  being  "  alien,"  "  artificial  " — mere  substitutes. 

2.  The  only  reliable  test  for  human  milk,  as  also  for  all  sub- 
stitutes, is  the  practical  one  of  experience. 

3.  Cow's  milk  is  practically  the  best  substitute  for  breast- 
milk,  but  should  never  be  given  to  young  infants  in  its  raw 
state — always  boiled,  parboiled  or  "sterilized." 


RECAPITULATION.  65 

4.  The  cereal  foods  should  never  be  given  for  any  considera- 
ble length  of  time,  except  in  combination  with  milk. 

5.  The  real  object  of  adding  cereals  to  milk  is  not  to  add  to 
its  nutritive  properties,  but  to  increase  its  digestibility. 

6.  This  they  accomplish  by  prolonging  the  digestive  act  and 
preventing  too  rapid  coagulation  into  large  masses  of  coarse 
curd. 

7.  The  cereals  best  adapted  for  infant  diet  are  barley,  oats 
and  wheat. 

8.  When  prepared  by  domestic  processes,  they  should  be 
thoroughly  cooked  until  the  starch  they  contain  is  more  or 
less  transformed  into  maltose. 

9.  Gum  arable,  gelatine,  or  any  other  bland  and  unirritating 
substance  may  be  added  to  milk  with  the  same  end  in  view. 

10.  All  artificial  infant  foods  should  be  given  at  the  body 
temperature,  100°  Fahr.,  and  through  a  clean  nursing  bottle. 

11.  Regularity  in  feeding  is  every  way  essential. 

12.  As  soon  as  an  infant  has  half  a  dozen  teeth  its  diet 
should  be  liberalized,  i,  e.,  varied  so  as  to  stimulate  the  devel- 
opment of  the  peptic  glands  and  increase  the  digestive  powers. 

D.  C— 5 


CHAPTER  VI. 

NURSERY    HINTS. 

Sanitary  science,  which  has  done  so  much  for  the  mother^ 
has  done  but  little,  if  anything,  for  the  baby.  Antiseptic  mid- 
wifery has  rid  the  lying-in  room  of  much  of  its  sufferings  and 
most  of  its  dangers.  But  the  nursery  is  still  the  home  of  diar- 
rhea, colic,  and  other  preventable  diseases,  which  are  or  should 
be  a  reproach  to  scientific  medicine.  Ophthalmia  neonatorum 
will  never  be  found  in  a  well-ordered  nursery,  where  proper 
cleanliness  is  observed  ;  and  all  forms  of  stomatitis  are  directly 
traceable  to  a  lack  of  care  in  the  management  of  the  infant's 
diet. 

A  babe  which  is  properly  bathed,  and  whose  skin  is  kept  iiv 
a  healthful  and  natural  condition,  should  never  have  eczema. 
There  will  be  space  here  for  only  a  few  hints  regarding  the 
baby's  home  and  its  sanitary  treatment.  If  pages  were  written 
until  they  were  multiplied  into  chapters,  and  these  chapters 
into  books,  the  gist  of  the  whole  thing  could  be  summed  up  in 
two  words — perfect  cleanliness. 

In  the  ideal  nursery  every  necessary  and  portable  utensil 
should  be  duplicated,  so  that  when  one  is  in  use,  another  is  being 
sterilized  or  rendered  aseptic  by  approved  methods.  This  ap- 
plies to  the  teaspoon,  the  nursing  bottle,  and  the  crockery. 
The  baby's  linen  and  the  diapers  should  receive  special  atten- 
tion, and  be  washed  and  dried  with  more  than  ordinary  care. 
When  possible,  the  antiseptic  properties  of  sunshine  should  be 
utilized  to  its  fullest  extent  in  this  connection.  The  infantile 
"  boss  of  the  home,"  should  not  only  have  the  freshest  of  milk,, 
and  the  best  the  house  affords  in  the  way  of  dietetics,  but 
scrupulous,  excessive  care  should  be  exercised  to  exclude  from 
his  surroundings  everything  calculated  to  irritate  the  hyper- 
sensitive skin,  or  poison  the  atmosphere  surrounding  his  sensi- 
tive and  susceptible  organism.  If  half  the  care,  forethought  and 
expense  were  given  to  the  rearing  of  human  beings  that  is  usu- 
ally deemed  necessary  in  the  breeding  and  rearing  of  stock,  the 
mortality  of  infants  under  five  years  of  age  would  soon  drop 
below  the  humiliating  figure  of  fifty  per  cent. 

The  only  two  points  necessary  to  dwell  upon  here  relate 
to  washing  and  dressing  the  infant.  Many  mothers  make 
(66) 


BABT'S  FIRST  TOILET— GERTRUDE  SUIT. 


67 


hard  work  of  both  proceedings,  because  they  do  not  know 
the  better  way. 

The  Baby's  First  Toilet.— A  new-born  baby  is  covered 
with  four  substances, — amniotic  fluid,  mucus,  blood,  and  ver- 
nix  caseosa.  The  first  three  of  these  are  easily  wiped  off 
when  the  baby  is  just  born,  the  last  can  best  be  softened  and 
removed  by  warm  sweet  oil.  So  immediately  rub  him  clean  of 
the  first  three  substances,  and  oil  him  from  head  to  foot  with 
the  warm  sweet  oil,  being  careful  to  rub  with  the  palmar  sur- 
face of  the  hand  and  fingers,  in  the 
groins,  armpits,  and  dorsum  where 
this  white  wax  is  most  abundant. 
Wiping  this  oil  and  vernix  off 
leaves  the  skin  as  soft  as  velvet. 

Dress  the  navel  with  absorbent 
cotton,  instead  of  burnt  linen,  as 
was  the  old  custom,  adjusting  a 
plain,  unhemmed  band  about  five 
inches  wide  just  tight  enough  to 
retain  the  navel  dressing  and  still 
be  entirely  comfortable  to  the 
baby. 

After  adjusting  the  diaper,  the 
dress  should  receive  attention.  The 
evolution  of  a  more  humane  and 
physiological  dress  for  the  baby 
has  created  much  interest.  To- 
day the  Gertrude  baby  dress  is  the 
most  comfortable  and  healthy,  as 
well  as  the  most  admired  infant 
costume  extant.  It  has  received 
the  encomiums  of  many  distin- 
guished physicians  in  this  country 
and  abroad,  as  well  as  the  kindly 
mention  of  thousands  of  mothers.  Said  a  happy  mother  in  a  let- 
ter to  the  author,  "  I  have  never  had  the  pleasure  of  seeing  you, 
but  my  baby  has  been  in  the  Gertrude  suit  for  eight  months 
and  if  you  have  done  nothing  else  in  your  life  but  give  this 
suit  to  the  babies,  you  may  still  count  your  life  a  success." 

The  Gertrude  Suit.* — The  undergarment  (see  Fig.  i)  is 
made  of  some  warm,  soft,  fleecy  material,  and  reaches  from  the 
neck  to  the  wrists,  and  to  eight  or  ten  inches  below  the  feet. 

*  Patterns  for  the  Gertrude  Suit  (five  in  a  set  for  $i.oo)  can  be  had  of  Gross  &  Del- 
bridge,  48  Madison  street,  Chicago. 


r.^. 


68 


THE  DISEASES  OF  CHILDREN. 


The  hems  and  seams  are  turned  upon  the  outside  so  that  it  is 
soft  and  fleecy  within. 

The  second  garment  (see  Fig.  2)  is  of  the  same  shape  as  the 
other,  with  the  same  princess  curves,  but  without  sleeves.  It 
is  an  inch  larger  than  the  other  one,  so  as  to  fit  over  it  comfort- 
ably. The  armholes  are  pinked  or  scalloped,  but  not  bound, 
so  as  to  be  easy  and  comfortable  to  the  baby.  This  middle 
garment  is  made  of  baby  flannel. 

The  dress  (see   Fig.  3)  is  of  any  material  you  like,  warmer  in 


ng.3' 


winter  and  cooler  in  summer,  but  of  the  same  shape,  only 
slightly  larger  so  as  to  fit  comfortably  over  the  others.  This 
may  be  made  as  simple  or  as  elaborate  as  you  please. 

These  three  garments  are  put  together  before  dressing, — 
body  within  body,  and  sleeve  within  sleeve.  After  diapering 
the  baby,  the  suit  is  put  over  its  head  as  one  garment,  the 
little  bare  arms  going  into  the  sleeves  without  friction  or  fret- 
ting. Tie  and  button  behind,  and  the  baby  is  dressed  with  one 
pin  instead  of  fifteen.  Each  garment  has  a  draw-string  tie  at 
the  neck  to  make  it  fit  a  baby  of  any  size.  These  tie  strings 
should  be  of  different  colors,  so  as  not  to  mismatch  in  tying. 


THE  BAIL  r  BA  TH.  Q9 

The  back  of  each  garment  is  opened  downwards  about  five  or 
six  inches,  and  in  the  middle  of  this  space  is  one  button,  so 
that  each  garment  has  a  tie  and  one  button  only. 

Never  put  two  buttons  on  the  baby's  dress  where  one  will 
serve.  Reduce  the  drudgery  of  motherhood  at  every  point, 
remembering  the  two  governing  principles  in  all  this  work  for 
our  babies  and  their  mothers, — namely,  health  to  the  baby  and 
ease  for  the  mother. 

The  nightgown,  of  some  soft  and  warm  material,  is  made  just 
like  the  undergarment  in  the  suit  (see  Fig.  i).  This  and  the 
diaper  is  all  the  baby  wears  at  night. 

The  diapers  are  of  canton  flannel  and  are  of  two  sizes,  the 
hems  being  upon  the  outside  and  turned  down  but  once.  The 
larger  one  is  eighteen  inches  square  and  the  smaller  one  ten 
inches  square.  This  smaller  one  is  so  adjusted  upon  the  larger, 
that  when  soiled,  we  have  a  small  diaper  to  wash  instead  of  a 
large  one. 

The  Daily  Bath. — Some  excellent  physicians  to-day  are 
sharply  criticising  the  daily  bath,  and  charging  it  with  many  of 
the  ills  of  infant  life.  It  is  undoubtedly  true  that  the  old  bath, 
so  tedious  and  fatiguing  to  the  mother  and  so  unpleasant  and 
exhausting  to  the  child  is  a  species  of  refined  cruelty  that 
should  be  relegated  to  the  things  of  the  past.  I  am  aware  that 
it  is  easy  to  find  fault  with  old  customs,  and  not  always  easy 
to  give  the  world  something  better ;  but  if  the  bath  is  properly 
given,  we  have  something  eminently  healthful  and  easy  to  put 
in  practice.  I  would  give  young  mothers  specific  directions  in 
this  matter.  • 

Make  all  preparations  for  the  bath  complete  before  touching 
the  baby.  Place  upon  the  carpet,  a  little  in  front  of  the  fire, 
a  rubber  sheet  a  yard  or  more  square.  Upon  this  an  infant's 
bath  tub,  half  full  of  water  at  the  proper  temperature,  say  92 
to  98  degrees,  but  the  mother's  instinct  will  guide  her  as  to 
what  will  please  the  baby  in  this  matter.  A  soft  sponge  or 
wash  cloth  is  thrown  in  the  water.  "  What  soap  shall  I  use  ?  " 
Not  any  for  the  first  two  years. 

The  lye  which  is  the  bottom  fact  in  all  soap  without  excep- 
tion is  unkind  to  a  young  baby's  skin,  and  it  is  most  unkind 
where  that  skin  is  the  thinnest,  behind  the  ears,  in  the  fat  folds 
of  the  neck,  under  the  arm-pits,  and  about  the  privates.  Since 
abandoning  the  use  of  soap,  excoriations  are  a  thing  of  the  past. 
You  can  make  a  baby  perfectly  clean  with  pure  water  and  the 
skin  will  be  as  soft  as  velvet.  There  is  an  oily,  sebaceous  nour- 
ishment to  the  skin  from  within,  rendering  it  soft,  pliable  and 
beautiful,  and   this  the  lye  of  the  soap  seeks  out,  leaving  the 


70  THE  DISEASES  OF  CHILDREN. 

skin  dry  and  harsh.  Pure  water  will  remove  the  dirt,  without 
disturbing  this  natural  dressing. 

Now  place  two  chairs  between  the  bath  tub  and  the  fire. 
Over  one  of  these  place  the  Gertrude  suit  all  nicely  adjusted. 
Over  this  a  soft  towel.  Over  the  other  chair  place  a  receiving 
blanket  (a  woolen  blanket  with  a  canton  flannel  one  inside), 
these  two  while  getting  thoroughly  warm  will  keep  the  heat 
from  you  while  giving  the  bath.  Fold  the  diaper  diamond 
shaped,  put  an  old  rag  in  it,  roll  it,  stick  a  pin  in  it,  place  it 
around  behind  the  chairs  on  the  warm  hearth. 

Now,  having  everything  ready,  take  the  baby  from  the  crib, 
remove  the  night-gown  and  diaper,  for  that  is  all  the  baby 
wears  at  night.  The  bandage,  the  shirt,  the  pinning-blanket, 
the  skirt  and  double-gown  are  a  bit  of  refined  cruelty  in  baby's 
preparation  for  sleep.  You  could  not  sleep  with  all  this  cum- 
bersome clothing.  Do  not  ask  your  baby  to.  Let  it  have  the 
same  delightful  freedom  which  you  enjoy  when  resting. 

With  the  naked  baby  in  your  hands,  kneel  upon  the  right 
knee  by  the  bathtub,  lay  the  baby  all  over  in  the  water,  save 
the  face,  the  head  resting  for  safety  in  the  palm  of  your  left 
hand.  With  the  free  right  hand  take  the  sponge,  and  begin  al- 
ways at  the  top  of  the  head.  Bathe  the  eyes,  ears,  nose,  mouth 
and  neck,  the  chest,  the  armpits,  and  the  privates  thoroughly 
and  so  down  to  the  feet.  Now  turn  the  baby  over,  his  chest 
resting  upon  the  palm  of  your  left  hand,  holding  it  high  enough 
to  keep  the  nose  and  mouth  out  of  water.  Then  with  the  free 
right  hand  take  the  sponge,  and  again  begin  at  the  top  of  the 
head,  bathing  successively  the  back  of  the  head,  the  neck,  the 
shoulders,  across  the  kidneys,  and  so  down  to  the  feet.  In  this 
way  you  know  whereto  begin  and  know  when  you  get  through. 
You  have  bathed  the  little  one  thoroughly  from  head  to  foot 
without  repeating  yourself  or  leaving  any  parts  untouched. 

Set  the  baby  up  in  the  end  of  the  bath  tub  and  draw  on  to 
your  lap  from  the  second  chair,  that  now  warm  receiving  blanket, 
place  the  baby  in  it,  wrapping  it  closely  to  the  neck,  tucking 
some  portions  of  the  inside  blanket  under  each  arm  and  be- 
tween the  limbs.  From  the  first  chair  take  the  warm,  soft  towel 
and  wipe  the  face,  head,  and  neck,  take  the  brush  and  part  the 
hair,  thus  making  the  toilet  complete  to  the  neck,  before  ex- 
posing the  body.  Now  set  the  baby  up  on  your  lap,  and  let 
the  blanket  fall  nearly  to  the  hips,  and  lo  !  baby  is  all  dry  ;  but 
a  little  brisk  rubbing  with  a  towel  or  the  palm  of  the  hand, 
will  make  a  bright  glow  upon  the  skin  and  rouse  capillary  cir- 
culation. 

Now  take  the  Gertrude  suit  all  warm  and  comforting  from 
the  first  chair,  place  it  all  over  baby's  head  at  once,  put  the 


SLEEP;   WHAT  IT  MEANS   TO  BABY.  71 

arms  in,  tie  and  button  behind,  and  the  baby  is  dressed  to  the 
hips  and  without  a  pin.  Lay  the  httle  one  down  upon  your 
lap  as  if  to  diaper  it,  and  now  for  the  first  time  expose  the  bot- 
tom and  limbs,  and  they  too  are  all  dry,  but  apply  a  little  brisk 
rubbing  as  before,  then  reach  around  the  chair  and  get  that 
warm  diaper  on  the  hearth  and  put  it  on  and  your  task  is  done 
— beautifully  and  healthfully  done.  You  have  bathed  and 
dressed  your  baby  easily  in  seven  minutes  instead  of  forty — 
the  time  which  the  average  nurse  and  mother  consume  in  this 
task. 

What  are  some  of  the  advantages  of  this  over  the  old  bath  ? 
Let  us  see.  In  the  first  place  you  have  saved  each  day  a  half- 
hour  of  exhausting  work,  making  one  hundred  and  eighty-two 
and  one-half  hours  saved  in  the  year,  simply  by  learning  to  do 
one  motherly  duty  right  instead  of  wrong.  Secondly,  it  means 
that  you  have  changed  a  trying  and  exhausting  duty  into  a 
mere  frolic,  highly  pleasurable  to  both  you  and  the  baby. 
Thirdly,  this  bath  has  a  wonderfully  quieting  influence.  Often 
when  called  to  children  in  convulsions,  I  have  placed  them  in  a 
quite  warm  bath,  when  they  would  return  to  consciousness  al- 
most immediately.  Now,  if  this  warm  full  bath  is  so  soothing 
as  to  take  a  baby  out  of  a  convulsion,  the  most  nervous  state 
in  which  it  is  ever  found,  it  must  be  very  tranquilizing.  And 
so  we  find  it.  This  bath  makes  a  baby  happy,  full  of  smiles, 
dimples  and  fun  all  cjay  long,  while  the  old  bath  and  dressing 
has  a  tendency  to  make  him  irritable. 

When  shall  we  bathe  the  baby  ?  Daily,  and  always  on  an 
empty  stomach.  A  good  time  is  just  before  the  second  nurs- 
ing. When  we  remember  how  essential  to  high  health  is  a  soft, 
velvety  skin ;  how  that  every  pore  is  a  minute  sewer,  and  that 
the  skin  itself  is  a  displayed  lung,  helping  to  oxygenate  the 
blood,  we  shall  appreciate  the  value  of  a  daily  bath. 

SLEEP  ;   WHAT   IT   MEANS   TO   BABY,  AND   HOW  TO   SECURE  IT. 

One  of  the  great  specialists  of  the  land  regards  sleep  as  a 
conservator  of  high  health,  and  says  it  will  do  much,  both  to 
prevent  and  cure  nervous  diseases  ;  that  if  he  could  get  into 
our  great  insane  asylums,  and,  by  any  fair  means,  induce  the 
inmates  to  have  eight  hours  of  sweet  sleep  at  night  and  one 
hour  during  the  day,  he  would  soon  send  the  bulk  of  them 
home  cured.  So  much  does  he  think  of  sleep  as  a  preventive 
and  panacea  for  nervous  diseases.  I  quote  him,  not  because 
he  is  peculiar  in  his  views,  but  because  he  voices  the  best 
thought  of  the  best  men  in  the  profession. 

A  large  proportion  of  the  diseases  of  infancy  are  nervous 


72  THE  DISEASES  OF  CHILDREN. 

diseases.  Look  at  all  the  cramps  and  convulsions  so  common 
in  early  life  ;  look  at  whooping-cough,  meningitis,  basilar  and 
cerebro-spinal ;  think  of  the  crying  spells,  the  insomnia,  the 
starting  from  sleep  at  the  slightest  noises. 

If  the  diseases  of  infant  life  are  nervous  diseases,  and  sleep 
will  prevent  and  cure  them,  how  important  it  is  to  sleep  the 
baby  abundantly.  "  But,"  says  the  young  mother,  "  the  more 
baby  sleeps,  the  better  I  like  it ;  you  won't  catch  me  waking 
baby  when  she  is  sleeping  sweetly."  That  is  all  right  as  far  as 
it  goes,  but  she  must  learn  to  conserve  baby's  habits  of  sleep. 

How  ?  First,  remember  the  necessary  conditions  of  rest  the 
world  over,  namely,  darkness  and  quiet.  The  lamp  burning  all 
night  spoils  the  first  condition,  and  the  frequent  hovering  over 
the  little  one,  defeats  the  second. 

Secondly,  have  regular  hours  for  sleep.  When  six  o'clock 
comes,  the  good  wife  undresses  the  baby  as  naked  as  it  was 
born,  rubs  it  with  a  Turkish  crash  towel,  puts  on  a  diaper  and 
nightgown,  nurses  it,  and  puts  it  to  bed.  This  is  a  finality;  it 
does  not  get  up  in  five  minutes,  or  one  hour,  or  two  hours.  It 
never  has  been  taken  up,  and  does  not  know  that  such  a  thing 
is  possible,  so  it  never  cries  to  get  up. 

After  a  second  nursing  each  day  it  goes  to  bed  for  a  two- 
and-a-half  hours'  nap.  How  do  you  get  your  baby  to  sleep? 
Do  you  sing  to  it,  or  rock  it,  or  walk  with  it  ?  By  no  means  ! 
We  put  it  in  the  crib,  kindly  cover  it,  and  let  it  go  to  sleep 
when  it  gets  ready.  It  kicks  up  its  heels,  plays  with  its  pink 
toes,  and  soon  drops  ofT  to  sleep. 

To  be  in  the  highest  health,  babies  should  sleep  all  night 
like  other  people,  and  this  should  be  taught  them  the  first 
week  of  their  lives,  by  simply  letting  them  alone.  The  band- 
age, shirt,  pinning  blanket,  skirt,  and  double  gown  are  dis- 
carded. You  could  not  sleep  with  all  this  load  of  clothing, 
nor  can  the  baby. 

When  put  to  bed  after  the  last  nursing,  let  it  absolutely 
alone  until  six  o'clock  in  the  morning.  But  what  shall  I  do  if 
it  cries  ?  It  will  not  cry,  it  has  a  healthy  father  and  mother,  it 
has  a  good  supper,  it  has  a  nice  warm  nest  to  lie  in,  it  is  a  rea- 
sonable baby  and  will  not  cry  for  nothing.  "  But,"  says  th,' 
nurse,  with  a  wise  shake  of  the  head,  "babies  will  cry  some- 
times." Yes,  kittens  mew,  dogs  bark,  and  colts  whinny,  but 
no  hurt  comes  to  them  from  these  healthful  exercises.  They 
do  not  rupture,  nor  will  the  baby,  grandmother  to  the  contrary, 
notwithstanding.  If  you  pick  that  little  one  up  to-night,  you 
will  have  to  to-morrow  night,  and  if  you  pick  it  up  to-night  and 
to-morrow  night,  the  mother  must  do  it  three  hundred  and 
sixty-five  nights,  and  she  should  not  be   thus   punished    for 


SLEEP;  HOW  TO  SECURE  IT.  73 

being  a  mother.  This  is  a  perfectly  easy  thing  to  do  if  you 
begin  the  first  night,  and  you  can  teach  the  baby  to  sleep  all 
night,  like  other  people,  before  it  is  a  week  old.  What  a  bless- 
ing this  habit  is  to  mother  and  child,  only  those  know  who 
have  tried  both  ways. 

Baby's  crib  should  be  open  work,  to  allow  ventilation.  The 
mattress  of  hair  should  have  over  it  a  pilch  and  a  sheet.  What 
kind  of  a  pillow  shall  we  have  ?  Well,  let  us  have  a  pretty 
pillow,  with  a  lace  border  and  a  blue  ribbon  run  in  about  the 
edge  to  put  into  the  crib  when  baby  is  not  there.  What,  can't 
I  have  a  nice,  downy  pillow  for  my  baby  to  sleep  on  ?  Well, 
I  will  tell  you  something,  and  then  you  may  decide  for  your- 
self. 

Baby  is  put  into  a  crib  with  a  soft,  downy  pillow,  it  settles 
down,  sleeps  soundly,  the  room  is  warm,  and  when  it  wakes,  it 
is  all  wet  behind  the  ears  and  back  of  the  neck.  It  is  taken 
up  and  carried  into  the  next  room  to  see  company,  it  takes 
cold  and  to-morrow  you  send  for  the  doctor.  Again,  this 
elevating  of  baby's  head  has  a  tendency  to  produce  round 
shoulders.  If  you  would  have  the  baby  grow  straight  and 
handsome,  let  him  sleep  on  a  straight,  flat  bed  for  the  first  few 
years.  Babies  love  to  lie  on  their  stomachs;  this  healthful 
and  enjoyable  position  they  cannot  assume  on  a  pillow. 

The  covering  of  the  baby  should  be  light  and  warm,  never 
burdensome.  If  you  put  your  hand  on  the  neck,  and  find  it 
wet  with  perspiration,  you  may  be  sure  it  is  too  warmly  cov- 
ered. If  at  any  time  during  the  year  you  find  the  baby  cross 
and  fretful,  stop  and  think  and  say  to  yourself,  "  Perhaps  I  am 
not  sleeping  the  little  one  as  much  as  I  ought  to;  I  will  give 
more  attention  to  the  proper  conditions  of  sleep."  In  this  way 
you  will  often  remedy  the  whole  trouble. 


PA  RT      II. 

DISEASES    OF    THE    EYE    AND    EAR. 


CHAPTER     I. 


DISEASES    OF    THE    EYE. 


The  eyes  of  the  infant  should  be  carefully  and  thoroughly 
examined  immediately  after  birth,  to  determine  the  probable 
condition  of  the  function  of  vision,  the  presence  or  absence  of 
congenital  defects,  and  the  possible  and  not  infrequent  reten- 
tion of  some  of  the  vaginal  secretions  within  the  conjunctival 
sac,  on  the  eye-ball,  eye-lashes,  or  upon  the  surface  of  the  lids. 

The  examination  thus  made  may  reveal  evidence  of  the  in- 
fant's eyes  having  suffered  from  inflammation,  while  yet  in  utero. 
When  present  such  conditions  are  the  result  of  syphilis,  either 
transmitted  from  the  father  direct  to  the  fetus,  from  the  ac- 
quired syphilis  of  the  mother,  or  from  heredity  of  one  or  both 
parents.  The  affections  thus  occurring  frequently  destroy  the 
sight,  partially  or  wholly,  before  birth,  and  usually  leave  such 
objective  changes  in  the  eyes  as  to  enable  us  to  determine  the 
part  which  has  been  diseased  and  also  the  extent  of  the  inflam- 
matory changes. 

Following  an  attack  of  fetal  iritis,  we  shall  find  the  iris  vary- 
ing in  color  from  that  normal  blue  of  all  infants  immediately 
after  birth,  the  pupillary  opening  perhaps  blocked  with  lymph 
or  adherent  to  the  lens  capsule,  the  latter  better  shown  by  the 
immobility  of  the  iris,  under  the  influence  of  light  varying 
in  intensity. 

The  cornea  may  present  a  whitish,  opaque  appearance,  the 
result  of  inflammatory  changes  in  its  substance,  the  extent  of 
the  loss  of  transparency  presented,  together  with  its  location  in 
the  cornea,  determining  a  proportionate  loss  of  vision  to  the 
infant. 

When  an  inflammation  of  the  choroid  has  occurred  in  fetal 
life,  no  external  expression  of  it  is  visible  in  the  eyes  until  some 
days  after  birth,  when  the  wandering  or  oscillatory  movement 
of  the  eye-balls  indicates  to  the  observant  physician,  that  the 
function  of  sight  is  impaired,  and  an  ophthalmoscopic  examina- 
tion usually  reveals  changes  in  the  choroid  and  retinae,  suffi- 
(74) 


DISEASES  OF  THE  ETE  AND  EAR.  75 

cient  to  account  for  the  restless  movements  of  the  eyes  of  the 
infant  in  its  instinctive  effort  for  better  vision.  Thus,  within 
its  first  month  of  life,  in  its  natural  endeavor  to  find,  aside  from 
the  impaired  central  and  most  sensitive,  some  other  portion  of 
the  retina  which  has  been  less  affected  by  the  choroiditis  from 
which  it  has  suffered  before  birth,  to  this  apparently  choreic 
motion,  the  term  nystagmus  has  been  given. 

The  normal  visual  power  of  the  infant  at  the  time  of  birth 
is  so  far  without  a  standard ;  yet  the  function  of  sight  of  the 
new-born  child  is  without  doubt  a  progressive  one. 

Some  years  ago  in  a  series  of  experimental  observations 
upon  the  infants  under  the  care  of  Dr.  George  E.  Shipman  at 
the  Foundlings'  Home,  I  was  able  to  satisfy  myself,  that  during 
the  first  month,  the  infant  has  but  little  vision  except  that  of 
light  perception.  The  impressions  of  objects  made  upon  the 
infantile  retina  seemed  to  be  absolutely  of  no  value,  except  as 
they  tended  to  excite  in  a  general  way,  the  ganglionic  cells  of 
the  optical  area  of  the  cortex  which  constitutes  the  visual  sphere. 

In  these  experiments,  and  in  the  light  of  later  investigations, 
the  observations  noted  by  me  at  that  time,  tend  to  determine 
the  fact,  that  even  in  the  first  weeks  of  infantile  life  the  excita- 
tion of  the  optic  nerve-fibers,  resulting  from  the  impression 
upon  the  retina  of  bright  lights,  and  such  necessarily  undefined 
forms  of  objects,  which  might  be  projected  upon  the  infantile 
retina,  are  at  the  same  time  sufficient  to  excite  a  stimulus  of 
the  ganglionic  cells  of  the  optical  area  of  the  cortex  so  as  to 
come  within  the  domain  of  consciousness  and  tend  toward  its 
development. 

In  the  early  life  of  the  infant,  I  am  satisfied  that  months 
must  pass  before  any  permanent  changes  may  result  in  the 
ganglionic  area  of  the  cortex,  which  will  enable  the  child  to 
retain  memory  pictures  of  the  things  seen. 

The  power  of  the  reproduction  of  well-defined  optical  mem- 
ory pictures  is  attained  ordinarily  only  after  the  first  or  second 
year  of  life,  and  is  dependent  upon  the  frequent  repetition  of 
the  same  retinal  excitation  for  the  objects  seen.  As  the  infant 
increases  in  age,  the  repetition  of  similar  images  becoming  more 
frequent  and  the  objects  more  varied,  a  rapid  development  of 
its  power  of  visual  consciousness  results,  and  the  increase  of  the 
power  of  reproduction  by  the  memory  of  those  things  which 
the  child  has  seen,  follows. 

The  retina,  optic  nerve,  and  the  ganglionic  cells  of  the  cun- 
eus  portion  of  the  brain  in  the  infant,  with  their  imperfect 
receptive,  conductive  and  absorptive  powers,  while  sufficient  to 
receive  perhaps  the  more  or  less  imperfect  image  on  the  retina, 
and  slowly  transmit  it  through  the  optic  nerve  to  the  bram,  it 


76  THE  DISEASES  OF  CHILDREN. 

is  probable  that  only  a  transient  impression  upon  the  optical 
memory  cells  of  the  cortex  results.  Imperfect  as  the  stimulus 
and  its  transmission  may  be  at  this  age,  it  is  at  the  same  time 
of  great  value  in  the  excitation  of  these  memory  cells,  which 
later  have  much  to  do  with  the  mental  and  even  the  physical 
development  of  the  child. 

The  new-born  infant  may  exhibit,  at  birth,  some  of  those 
anomalous  conditions  of  the  eyes,  which  occur  from  arrested  or 
imperfect  development  which  are  classed  as  congenital  defects, 
which,  when  present,  may  have  a  visual,  cosmetic,  or  surgical 
value. 

To  the  physician  who  has  conducted  the  infant  into  this 
world  without  other  evidence  of  monstrosity,  there  is  perhaps, 
nothing  more  appalling  than  the  presentation  to  the  nurse,  or 
the  mother,  of  a  child  without  eyes  (anopthalmus). 

The  infant  emerging  from  the  inner-world  of  the  mother  to^ 
the  outer-world  of  light,  separates  its  lids  involuntarily  for  the 
purpose  of  stimulating  its  imperfect  retina  by  the  admission  of 
light  to  further  its  development.  If  the  lids  do  not  open  at  birth 
and  thus  expose  the  cornea  and  pupil  to  the  observation  of  the 
physician,  he  must  determine  whether  the  fault  lies  in  an  ina- 
bility to  open  the  eyes  because  of  inervation  of  the  levator  of 
the  upper  lid  (congenital  ptosis) ;  or  because  from  arrested  de- 
velopment the  fissure  of  the  lids  has  not  been  completed  and 
their  free  margins  remain  united  (ankyloblepharon) ;  the  lat- 
ter condition  at  birth  frequently  covering  the  defect  due  to 
absence  of  the  eye-balls  (anophthalmus);  or  their  imperfect 
development  when  the  eyes  are  abnormally  small  (microph- 
thalmus). 

Among  the  other  defects  to  be  noticed  are  the  absence  of  the 
eyelids  (ablepharon)  which  occurs  only  in  monstrosities ;  the 
displacement  of  the  normal  opening  of  the  lids  from  a  hori- 
zontal position  to  an  angular  one  (ectopia  tarsi),  which  gives 
the  child  a  Mongolian  aspect ;  or  when  there  is  a  vertical  fis- 
sure of  the  lids  (coloboma),  usually  the  upper  being  the  one 
affected,  although  the  lower  or  even  both  may  exhibit  this 
defect. 

Again  it  may  be  noticed  that  one  or  both  lids  may  be  in- 
verted (entropion)  or  there  may  be  an  over-development  of  the 
cilia  and  two  lines  of  eyelashes  (distichiasts)  be  present,  the 
inner  row  causing  irritation  of  the  cornea  and  eyeball. 

Sometimes  a  redundant  fold  of  skin  may  show  itself  at  the 
bridge  of  the  nose,  and  by  its  fullness  cover  the  inner  canthus- 
of  each  eye  sufficiently  to  cause  a  deformity  and  perhaps  inter- 
fere with  the  vision  and  the  opening  of  the  lids.  This  deform- 
ity (epicanthus)  may  be  lessened  or  dissipated  in  some  cases 


DISEASES  OF  THE  EYE  AND  EAR.  77 

by  the  removal  of  a  vertical  elliptical  piece  of  the  skin  at  the 
dorsum  of  the  nose,  and  yet  if  the  fold  of  skin  is  not  too  great 
in  flat-nosed  children,  the  deformity  may  disappear  without 
operation  in  from  four  to  six  years,  with  the  development  of 
the  nose  bridge. 

Vascular  naevi  or  other  birthmarks  may  exhibit  themselves 
and  require  surgical  treatment  soon  after  birth,  owing  to  their 
extent,  or  later,  when  in  the  judgment  of  the  surgeon  their  dis- 
appearance with  the  development  of  the  child  is  not  probable. 

The  presence  or  absence  of  the  lachrymal  apparatus  is  rarely 
noticed  immediately  after  birth,  and  it  may  be  weeks  or  months 
later  that  the  congenital  defects  of  imperfect  development  of 
the  puncta,  canaliculus,  or  lachrymal  ducts  cause  attention  by 
the  overflow  of  tears  or  the  presence  of  pus  or  muco-pus  at  the 
inner  canthus.  The  lachrymal  gland  in  rare  cases  is  found  to 
be  absent  or  undeveloped  ;  the  usefulness  of  the  eye,  however,  is 
not  necessarily  impaired  by  its  absence. 

If,  as  is  rarely  the  case  except  in  lying-in  asylums,  found- 
lings' homes,  or  other  similar  institutions,  a  careful  examination 
of  the  eyes  of  the  new-born  is  made  by  a  skilled  medical  attend- 
ant, other  defects  arising  from  arrested  development  which  im- 
pair the  sight  are  often  found  present  in  eyes  which  to  the  less 
skilled  observer  would  pass  for  normal  eyes. 

The  iris  may  be  absent  (irideremia),  or  show  a  cleft,  the  fis- 
sure being  generally  below  (coloboma  of  the  iris),  a  displace- 
ment of  the  pupil,  inward,  outward,  upward,  or  downward 
(corectopia),  or  there  may  be  more  than  one  pupil  (polycoria), 
in  some  cases  the  abnormal  position  of  the  pupil  causing  both 
imperfect  vision  as  well  as  a  cosmetic  defect. 

With  the  opthalmoscope  we  look  into  the  interior  of  the  eye 
and  find  where  nature  failed  to  complete  its  work  for  the  indi- 
vidual, as  in  the  pupil,  which  should  be  free  of  all  obstruction 
for  the  purpose  of  vision,  shreds  of  membrane  are  seen  to 
stretch  across  its  area  (persistent  pupillary  membrane)  and  which 
interfere  more  or  less  with  the  ultimate  vision  of  the  infant. 
It  may  be  found  that  the  lens  is  not  in  its  normal  position 
and  that  by  some  freak  of  development  it  is  displaced  (luxatio 
lentis  congenitalis),  or  that  certain  layers  of  its  tissue  are  opaque 
and  a  diagnosis  of  lammellar  or  zonular  cataract  is  made.  Not 
infrequently  the  whole  lens  is  opaque  at  birth  and  congenital 
cataract  should  be  diagnosed. 

If  the  lids,  cornea,  iris,  lens  or  vitreous  are  normal,  we  may 
find  on  ophthalmoscopic  examination  that  there  may  be  evi- 
dence  of  arrested  development  in  the  posterior  portion  of  the 
eye,  perhaps  what  is  called  a  persistent  hyaloid  artery,  a  blood 
vessel  running  from  the  optic  disk  to  the  posterior  portion  of 


78  THE  DISEASES  OF  CHILDREN. 

the  lens,  originally  intended  for  the  development  of  the  latter, 
but  which  failed  to  be  absorbed  and  thus  by  its  presence 
interferes  with  the  vision  of  the  eye ;  or  there  may  be  an 
opening  in  the  choroid  (coloboma)  which  has  impaired  the 
development  and  sensibility  of  the  overlying  retina  at  this 
portion. 

It  is  not  unlikely  that  we  may  find  in  the  investigation  of  the 
depths  of  the  eyes,  that  more  or  less  of  the  optic  nerve  fibers, 
which  enter  the  eyeballs  through  the  opening  in  the  sclera, 
have  not  been  denuded  of  their  opaque  sheaths  and  present  to 
our  view  a  radiating  opaque  white  mass  which  we  have  learned 
to  recognize  as  opaque  optic  nerve  fibers. 

In  some  cases  deposits  of  pigment  may  be  observed  upon  or 
around  the  optic  disk,  but  like  the  opaque  nerve  fibers,  have 
no  special  relation  to  the  visual  functions  unless  the  lesion  is 
an  extensive  one. 

In  infancy  and  childhood,  there  are  certain  acute  diseases  of 
the  eye,  which  require  early  recognition  on  the  part  of  the 
physician,  who  should  be  able  to  diagnose  and  prognose  the 
condition,  even  if  he  does  not  feel  that  he  can  do,  from  want  of 
experience,  what  a  specialist  might.  The  ophthalmic  surgeon 
is  only  a  specialist  because  of  years  of  practice  confined  to  his 
department  of  medicine,  in  which  he  has  acquired  a  knowledge 
or  a  technique  from  the  large  number  of  special  eye  cases  which 
come  to  him,  that  the  general  practitioner  cannot  avail  him- 
self of. 

Following  the  examination  of  the  eyes  of  the  infant  as  out- 
lined above,  if  we  should  find  upon  the  lids,  eyelashes,  or  within 
the  conjunctival  sac  of  the  eye  any  extraneous  matter  and  our 
search  for  it  should  be  the  more  thorough,  if  we  have  suspicion 
or  knowledge  of  a  specific  disease  of  the  genital  organs  of  the 
mother,  or,  if  a  marked  or  acrid  leucorrhoea  exists,  the  presence 
of  such  matter  endangering  the  eyes  by  possible  inoculation. 
Such  conditions,  when  present  in  the  mother,  are  too  often  fol- 
lowed by  destructive  inflammation  of  the  eyes  of  her  infant. 

Ophthalmia  Neonatorum,  is  a  term  applied  to  one  of  the 
most  frequent  of  the  inflammations  of  the  eye  in  infancy,  and 
is  a  purulent  inflammation  of  the  conjunctiva  of  the  new-born 
child.  It  is  a  disease  which  is  usually  violent  in  its  outset  and 
rapidly  destructive  of  sight. 

While  in  the  last  few  years,  although  scientific  medicine  has 
reduced  the  percentage  of  blindness  resulting  from  it,  from 
seventy  to  thirty-five,  it  still  furnishes  the  largest  number  of  the 
inmates  of  our  blind  asylums. 

Such  being  the  case,  it  is  necessary  that  the  physician  who 


PROPHTLAXIS—STMPTOMS;  DIAGNOSIS.  7D 

attends  mother  and  child,  should  be  alert  to  discover  the  con- 
dition of  the  infant's  eyes,  and  also  to  avoid  it,  if  possible,  by- 
proper  care  of  the  mother  before  parturition. 

Prophylaxis. — It  is  important  and  necessary  to  exercise 
the  most  rigid  care  to  prevent  infection  of  the  eyes  of  the  in- 
fant, by  careful  disinfection  of  the  vagina  before  and  during 
parturition  in  all  cases  where  a  specific  or  acrid  leucorrhoea, 
whether  cervical  or  vaginal,  exists  in  the  mother. 

When  the  mother  presents  an  acrid  leucorrhoeal  or  gonor- 
rhoeal  discharge,  or  a  vaginal  discharge  of  whatever  character, 
the  most  scrupulous  attention  should  be  given  to  its  correction 
prior  to  confinement.  The  use  of  cleansing  lotions  of  large 
quantities  of  warm  water,  containing  carbolic  acid,  boracic  acid, 
sulphate  of  zinc,  or  glycerole  of  tannin,  for  several  days  prior 
to  confinement  will  undoubtedly  lessen  the  danger  of  infection. 
After  the  birth  of  the  child,  and  before  the  cord  is  severed,  the 
physician  should  at  once  cleanse  the  eyelids  with  bits  of  soft 
linen,  or  absorbent  cotton  ;  remove  all  secretion  from  the  cilia, 
and  wash  the  eyelids  and  surrounding  parts  in  a  saturated 
solution  of  boracic  acid. 

When  we  have  reason  to  suspect  that  danger  of  inocula- 
tion is  probable,  we  should,  as  soon  as  the  child  has  been  other- 
wise cared  for,  evert  the  lids  to  discover  and  remove  any  of  the 
unctuous  material  mixed  with  leucorrhoeal  discharge  which 
may  have  insinuated  itself  beneath  the  lid,  and  found  a  resting- 
place  upon  the  folds  of  the  conjunctiva. 

Symptoms  and  Diagnosis. — The  most  typical  cases  of  oph- 
thalmia neonatorum  occur  from  twelve  to  seventy  hours  after 
birth.  Usually  before  the  third  day  we  find  the  eyelids  some- 
what reddened,  slightly  swollen,  and  a  slight  flow  of  tears. 
Eversion  of  the  lids  will  show  bright  red  transverse  lines  occupy- 
ing the  middle  of  the  palpebral  conjunctiva  ;  shortly  after  this, 
the  edges  and  angles  of  the  lids  become  red,  and  perhaps  pain- 
ful on  pressure.  The  ocular  conjunctiva  is  next  to  become 
involved  ;  it  appears  bright  red,  and  the  swelling  of  the  lids  in- 
creases. The  discharge  which  at  first  was  almost  entirely  of 
tears,  now  becomes  serous,  and  gradually  assumes  the  appear- 
ance of  turbid  whey.  There  is  considerable  photophobia,  which 
causes  the  infant  to  close  the  lids  tightly,  so  that  some  diffi- 
culty is  experienced  in  opening  them.  This  closes  the  first 
stage.  The  second  stage,  or  that  of  suppuration,  is  ushered  in 
usually  by  a  marked  increase  in  the  swelling  of  the  lids.  This 
swelling  increases  so  rapidly  that  often  in  twenty-four  hours 
they  cannot  be  separated  without  considerable  force.  The 
upper  lid  usually  overlaps  the  lower  one,  and,  in  most  cases,  is 


80  THE  DISEASES  OF  CHILDREN. 

SO  stiff  that  it  is  difficult  or  impossible  to  turn  it.  On  separat- 
ing the  lids  the  exposed  conjunctiva  is  thickened,  perhaps 
raised  in  folds,  and  of  a  diffused  bright  red  hue  through  which 
the  sclera  can  be  dimly  seen.  At  first  there  is  a  muco-purulent 
coating  over  the  entire  conjunctival  surface;  the  discharge 
soon  becomes  more  abundant  and  decidedly  purulent,  and  later 
is  thick  and  creamy.  The  effusion  into  the  conjunctiva  is  gen- 
erally serous  and  causes  chemosis  or  swelling  of  the  conjunc- 
tiva of  the  eyeball  and  protrusion  of  the  lids,  but  in  some  cases 
contains  much  fibrin,  and  the  conjunctiva  presents  a  raised  and 
resisting  surface  in  that  portion ;  this  condition  arises  more 
particularly  in  the  course  of  gonorrhoeal  infection,  and  is,  of 
necessity,  very  grave,  owing  to  the  danger  to  the  cornea  from 
the  compression  of  the  vessels  which  supply  it.  When  the  ef- 
fusion is  very  great,  the  swelling  of  the  ocular  portion  may 
extrude  between  the  lids,  and  the  palpebral  swelling  causes 
eversion  of  the  lids,  the  latter  giving  rise  to  a  spasmodic  action 
of  the  orbicularis,  or  blepharospasm,  which,  by  increasing  the 
pressure  upon  the  eyeball,  causes  increased  danger  to  the 
cornea. 

As  the  inflammation  increases  the  secretion  of  pus  becomes 
enormous,  considering  the  small  area  of  the  suppurating  surface. 
The  free  edges  of  the  lids  are  stuck  together  by  the  discharge 
drying  upon  them,  and  their  separation  causes  the  discharge  to 
gush  out  with  some  force,  and  oftentimes  with  danger  to  the 
operator.  The  cornea  is  thus  kept  macerating  in  the  impris- 
oned pus.  The  cutaneous  surface  of  the  lids  is  livid,  traversed 
by  enlarged  veins  from  the  passive  congestion.  Early  in  the 
second  stage  it  is  usual  to  notice  unmistakable  signs  of  pain. 
There  may  be  some  marked  febrile  reaction,  the  child  becomes 
restless  and  refuses  the  breast.  If  the  local  affection  is  slight, 
the  child  usually  thrives.  In  the  majority  of  cases  of  ophthal- 
mia there  is  no  further  advance  of  the  disease ;  the  inflamma- 
tion having  reached  its  height  now  begins  to  subside,  and 
usually  results  in  complete  recovery,  without  sequelae.  Some 
cases,  however,  pass  into  a  chronic  catarrhal  inflammatory  con- 
dition, and  in  others  the  papillae  become  hypertrophied  or  true 
granulations  result.  If  the  cases  do  not  end  here,  irreparable 
damage  results  from  the  third  stage  which  is  entered  upon,  in 
which  we  have  involvement  of  the  cornea  in  the  inflammation. 
This  complication  is  more  frequently  the  result  of  gonorrhoeal 
infection  or  of  badly  treated  or  neglected  cases. 

The  cornea  may  exhibit  the  effect  of  the  destructive  process 
at  small  points  or  over  its  whole  surface.  The  corneal  affection 
usually  appears  in  from  eight  to  ten  days  after  the  disease  has 
become  established.     The  corneal  epithelium  is  lost  from  con- 


PR  OPHTLA  XIS—  TREA  TMENT.  81 

stant  maceration  in  the  pus,  and  the  cornea  presents  at  first  a 
hazy  or  milky  appearance,  which  soon  becomes  yellowish  and 
finally  ends  in  complete  suppuration,  rupture  of  the  cornea  and, 
perhaps,  loss  of  the  lens,  extrusion  of  the  iris  and  atrophy  of 
the  bulb.  If  the  disease  is  arrested  before  suppuration  of  the 
cornea  is  complete  the  eye  recovers  with  a  nebulous  cornea, 
presenting  much  the  appearance  of  ground  glass;  this  con- 
dition may  clear  up  very  much  owing  to  the  activity  of  the 
absorbents  in  infancy,  a  result  which  may  be  hastened  by  the 
assistance  of  certain  homeopathic  remedies. 

In  another  class  of  cases  we  may  have  one  or  more  minute 
grayish  points  of  corneal  infiltration  and  softening  which  give 
rise  to  ulceration  and  perforation.  In  others  still,  the  whole 
cornea  may  slough,  as  the  result  of  the  strangulation  of  the 
vessels  by  the  chemotic  swelling,  so  that  on  the  second  or 
third  day  the  eye  is  entirely  destroyed.  In  the  milder  cases  of 
strangulation  of  the  blood-vessels  of  the  cornea  which  nourish 
it,  there  may  be  one  or  more  rapidly  spreading  central  or  mar- 
ginal ulcers,  which  appear  as  if  portions  of  the  cornea  had  been 
chipped  out,  with  clean  cut  edges  and  transparent  bases  which 
are  difficult  to  detect  unless  viewed  by  oblique  illumination. 
These  are  more  difficult  to  heal  than  the  others ;  the  edges 
become  rounded,  blood-vessels  develop  in  them  and  they  rap- 
idly fill  up. 

As  a  rule,  both  eyes  are  affected  simultaneously,  or  in  rapid 
succession  ;  at  times,  one  eye  is  infected  and  the  other  remains 
free.  In  all  cases  the  eye  should  be  carefully  examined  by  the 
medical  attendant,  and  to  do  this,  the  discharge  should  be  care- 
fully removed  from  the  lid  margins  and  lashes,  and  then  the 
eyelids  separated  by  the  fingers  applied  above  and  below,  or  if 
necessary,  small  retractors  should  be  used  ;  having  in  this  man- 
ner obtained  a  view  of  the  whole  anterior  portion  of  the  eye- 
bail,  the  cornea  should  be  thoroughly  examined.  The  duration 
of  the  disease  is  from  three  to  six  weeks,  and  much  longer  if 
improperly  treated,  or  neglected. 

Treatment. — The  eyes  should  be  shaded  from  the  light,  but 
it  is  not  necessary  to  confine  the  infant  to  a  darkened  room ; 
rather  place  it  in  a  light  and  well-ventilated  apartment.  The 
success  of  the  treatment  depends  upon  the  frequent  removal  of 
the  discharges,  the  eyes  being  constantly  cleansed  with  scraps 
of  old  linen  orbits  of  absorbent  cotton,  and  the  further  cleans- 
ing of  the  eyes  with  solutions  of  chlorine  water  diluted  one-half, 
boracic  acid  (gr.  X.  ad  /^i.),  or  arg.  nit.  (gr.  i.  ad  f^x)  injected 
into  the  eye  from  an  eye-dropper,  and  the  use  of  vaseline  to  the 
lid  edges  will  be  sufficient  to  carry  the  majority  of  cases  to  a  fa- 
vorable termination  without  other  remedies.     The  use  of  cold 


82  THE  DISEASES  OF  CHILDREN. 

compresses  is  not  applicable  to  such  young  infants,  but  in  case 
corneal  affections  appear,  frequent  bathing  of  the  eyes  with 
warm  water  every  five  minutes  during  the  day,  and  every 
quarter-hour  at  night,  and  the  use  of  a  solution  of  atropine 
(gr.  ^  ad  /gi.),  one  drop  every  three  hours,  will  be  indicated. 
The  careful  following  of  the  directions  for  the  removal  of 
the  discharge  and  the  administration  of  arg.  nit.,  6th  to 
30th,  puis.,  mere,  or  hepar  sulph.,  will  be  sufficient  to  bring- 
the  cases  to  a  favorable  termination.  Other  remedies  may  be 
useful  and  their  indications  will  be  found  under  Conjunctivitis 
Purulenta. 

Catarrhal  Conjunctivitis  of  the  new-born  infant  often 
presents  itself  within  the  first  weeks  of  its  new  life.  The 
secretion  of  the  inflamed  conjunctiva  is  often  muco-purulent, 
instead  of  being  mucoid  ;  the  lessened  intensity  of  the  symp- 
toms enables  us  to  differentiate  this  affection  from  that  just 
described. 

Etiology, — The  inflammation  seems  to  arise  from  exposure 
to  var>'ing  temperature,  to  want  of  proper  protection  during 
the  bath,  the  want  of  proper  hygienic  surroundings,  careless- 
ness upon  the  part  of  the  nurse  in  cleansing  the  eyes  or  the 
transferrence  of  foreign  matter  to  the  eyes  from  the  fingers  or 
cloths  used  by  the  attendant.  Undoubtedly  the  exposure  of 
the  eyes  of  the  infant  to  strong  and  bright  lights,  occasions 
in  some  cases  the  inflammatory  reaction. 

Symptoms. — There  is  usually  some  swelling  of  the  lids,  the 
eyeballs  present  a  more  or  less  bloodshot  appearance.  There 
is  also  anxiety  and  restlessness  of  the  child  due  to  the  discom- 
fort of  the  eyes,  which  interferes  with  its  sleep. 

The  discharge,  at  first  watery,  becomes  mucoid,  collects  upon 
the  lids  and  eyelashes  and  causes  their  adherence. 

The  discharge  never  presents  that  yellowish  color,  creamy 
consistence  nor  quantity  that  is  found  in  the  purulent  conjunc- 
tivitis. 

Prognosis. — As  the  symptoms  are  more  mild  than  in  the 
purulent  form,  the  danger  to  vision  is  slight,  as  the  cornea  is 
seldom  affected,  and  the  disease  is  capable  of  spontaneous 
cure  in  the  majority  of  cases,  within  a  week  or  two  of  its 
inception.  The  greatest  danger  is  from  a  possible  chronicity, 
which  may  occasion  the  development  of  true  trachoma  or 
granular  lids  later,  as  is  commonly  the  case  in  ophthalmia 
neonatorum. 

Treatment. — The  use  of  some  mild  collyria,  such  as  the 
borax,  boracic,  alum  or  tannic  acid  glycerine,  together  with  the 
internal  use  of  aconite,   euphrasia,  hydrastis,  sulphur,  mercu- 


PHLYCTENULAR  CONJUNCTIVITIS.  83 

rius,  or  argent  nit.,  are  sufficient  to  hasten  the  cure  and  lessen 
the  danger  of  any  chronic  condition  resulting. 

Phlyctenular  or  Pustular  Conjunctivitis  is  a  recur- 
rent form  of  inflammation,  characterized  by  the  appearance  of 
one  or  more  vesicles  or  papules  upon  the  ocular  conjunctiva, 
supposedly  around  the  terminal  filaments  of  the  branches  of  the 
fifth  nerve,  and  often  occurring  near  the  cornea.  Each  papule 
or  phlyctenule  forms  a  small  patch  of  localized  congestion  to- 
wards which  converge  a  leash  of  vessels  which  can  frequently  be 
traced  back  to  the  folds  of  the  conjunctiva.  These  phlycten- 
ules  may  present  a  semi-transparent  or  yellowish  elevation  or 
be  more  flat,  large,  and  give  the  appearance  of  a  gelatinous  in- 
filtration  at  that  point.  There  may  be  one  or  many  scattered 
over  the  ocular  conjunctiva,  or  aggregated  at  the  corneal  margin, 
or  they  may  encircle  it  and  appear  upon  the  cornea  also.  In  a 
few  days  the  vesicle  which  forms  the  summit  of  the  phlycten. 
ule,  ruptures  and  leaves  a  shallow  ulcer  with  a  yellowish  base 
which  heals  in  a  few  days.  In  some  cases  small  points  of  con- 
gestion  only,  appear  and  after  a  short  time  subside  without  the 
formation  of  a  vesicle.  The  pain  is  usually  not  severe,  the 
photophobia  or  dread  of  light  variable,  and  in  some  cases  very 
slight,  in  others,  intense  and  accompanied  by  severe  blephar- 
ospasm. The  secretion  is  commonly  scant  and  mucoid  in 
character. 

The  disease  shows  a  great  tendency  to  recur  and  the  phlyc- 
tenules appear  in  successive  crops  after  the  lapse  of  weeks  or 
months.  They  are  very  prone  to  appear  in  the  winter  and 
spring.  Children  have  a  peculiar  liability  to  the  disease,  as  it  is 
only  rarely  seen  in  adults,  and  may  be  considered  as  indicative 
of  some  derangement  of  the  general  health.  It  is  common  to 
delicate  and  ill-nourished  children,  particularly  those  who  live 
upon  an  almost  exclusively  starch  diet,  or  use  tea  and  coffee. 

Treatment. — The  treatment  consists  in  the  improvement 
of  the  general  tone  of  the  patient,  and  the  restriction  of  such 
nerve  stimulants  as  tea  and  coffee.  The  patient  should  be 
urged  to  live  upon  a  mixed  diet,  as  many  cases  cannot  be  cured 
until  a  moderate  amount  of  nitrogenous  food  enters  into  the 
daily  nourishment.  External  applications  are  rarely  necessary, 
as  the  cure  is  much  more  rapid  and  permanent  by  the  use  of  in- 
ternal remedies  than  with  topical  applications.  Of  the  latter, 
those  which  are  generally  recommended  are  the  yellow  oint- 
ment, a  small  bit  of  which  is  introduced  between  the  lids  and 
allowed  to  melt  upon  the  conjunctiva,  calomel  or  flowers  of 
sulphur  dusted  upon  the  phlyctenule,  or  solutions  of  mere.  nit. 
dropped  into  the  eye. 


84  THE  DISEASES  OF  CHILDREN. 

REMEDIES. 

Sulphur. — Very  frequently  indicated  in  cases  occurring  in 
scrofulous  children.  Its  sphere  of  action  is  very  wide  and 
suits  a  great  variety  of  cases  of  pustulous  inflammation  of  the 
conjunctiva,  and  is  particularly  indicated  when  there  are  sharp, 
darting,  lancinating  pains,  or  as  if  pins  and  needles  were  sticking 
in  the  eye  during  the  day,  or  if  the  pains  aggravate  after  mid- 
night. There  may  also  be  itching,  often  a  thickened  condition 
of  the  lid  and  much  rubbing  of  the  eyes.  The  photophobia  is 
variable  and  may  be  quite  marked  in  the  morning.  The  lach- 
rymation  is  usually  profuse  and  the  lids  generally  stick  together 
on  awakening. 

There  is  often  an  eczematous  condition  of  the  lids,  face  and 
head,  and  general  aggravation  from  the  application  of  cold  water, 
or  from  bathing  the  eyes. 

Pulsatilla. — The  phlyctenules  are  more  frequently  of  the 
small  variety,  but  often  numerous ;  the  photophobia  or  pain  is 
commonly  slight  and  the  redness  variable.  The  lachrymation 
and  discharge  are  moderate  and  bland,  although  it  is  not  con- 
tra-indicated if  the  secretions  are  profuse.  Particularly  suit- 
able to  the  blonde  women  and  children  upon  whom  pulsatilla 
seems  to  have  so  good  an  action. 

Mercurius  Sol. — A  valuable  remedy  in  many  cases  of  phlyc- 
tenular inflammation  in  strumous  or  syphilitic  children.  There 
is  usually  marked  redness  of  the  conjunctiva,  and  violent  pho- 
tophobia, so  that  all  light  must  be  excluded,  and  the  discharge 
usually  thin  and  acrid.  The  pains  are  severe  and  neuralgic  in 
character,  affecting  the  temporal  side  of  the  head  and  face. 
They  are  variously  described  as  burning,  sharp,  tearing,  and 
lancinating,  and  aggravated  in  the  evening  and  from  the  expo- 
sure of  the  eyes  to  artificial  light,  by  heat  and  damp  weather, 
while  there  is  a  temporary  relief  from  application  of  cold  water 
to  the  eyes.  The  lids  are  often  thick  and  swollen  and  spasmodic- 
ally closed  and  excoriated  by  the  discharge. 

Merc.  Cor. — Indicated  in  the  aggravated  form  of  inflamma- 
tion occurring  in  scrofulous  children.  The  symptoms  are  much 
more  marked  than  in  the  other  preparations  of  mercury,  the 
pains,  photophobia,  lachrymation,  all  being  aggravated ;  the 
nostrils  are  often  excoriated  by  the  acrid  discharge  from  the 
eye,  passing  down  into  the  nose. 

Mercurius  Dulcis. — Although  calomel  is  used  very  exten- 
sively by  the  old  school  in  scrofulous  ophthalmia,  it  is  but  rarely 
applicable  to  phlyctenular  inflammation ;  some  cases,  occurring 
in  pale,  flabby  subjects,  with  excoriation  of  the  nose,  and  swell- 
ing of  the  upper  lip,  have  been  benefited. 


REMEDIES.  85 

Mercurius  Nit. — This  remedy,  recommended  by  Dr.  Liebold, 
was  used  by  him  with  remarkable  success  in  a  great  variety  of 
cases  of  phlyctenular  inflammation.  It  seems  to  suit  severe  as 
well  as  mild  affections,  acute  or  chronic,  with  or  without  much 
photophobia,  and  in  some  cases  presenting  severe  pain,  in 
others  where  the  pain  is  absent.  It  may  be  used  both  inter- 
nally and  externally.  If  externally,  ten  grains  of  the  first  deci- 
mal trituration  are  to  be  dissolved  in  two  drachms  of  water  and 
applied  by  means  of  a  camel's  hair  brush  to  the  phlyctenule 
two  or  three  times  a  day. 

Graphites. — This  is  one  of  the  most  valuable  remedies  we 
have  for  all  forms  of  phlyctenular  inflammation.  It  is  useful 
in  both  the  acute  and  chronic  forms,  particularly  in  cases  where 
there  is  a  marked  tendency  toward  recurrence.  It  is  specially 
•indicated  in  scrofulous  cases,  or  with  exanthematous  eruptions 
about  the  head  or  behind  the  ears,  particularly  where  the  erup- 
tions are  glutinous,  fissured  and  bleed  easily.  The  photopho- 
bia is  usually  very  marked,  and  the  lachrymation  profuse, 
although  in  some  cases  nearly  or  entirely  absent.  There  is 
generally  a  greater  aggravation  from  sunlight  than  from  gas- 
light, and  in  the  morning,  so  that  often  the  child  cannot  open 
the  eyes  before  nine  or  ten  o'clock.  The  conjunctiva  is  fre- 
quently very  red,  and  the  discharges  are  muco-purulent,  con- 
stant, thin  and  excoriating.  The  pains  are  variable  and  not 
characteristic,  the  lids  are  sore,  red  and  agglutinated  in  the 
morning,  or  else  covered  with  dry  crusts,  while  the  external 
canthi  are  fissured  and  bleed  easily  upon  opening  the  eye. 
There  may  be  also  an  acrid  discharge  from  the  nose  accom- 
panying the  eye  affection. 

Calc.  C«r^.— Phlyctenules  occurring  in  fat,  unhealthy  chil- 
dren,  with  pale,  flabby  skin  and  enlarged  glands.  The  pho- 
tophobia is  often  excessive,  and  the  lachrymation  very  great 
and  often  acrid.  The  redness  and  pains  (sticking  in  character) 
are  variable  and  the  lids  perhaps  swollen  and  glued  together  in 
the  morning. 

Calc.  Sulph.—V^iW  prove  exceedingly  valuable  in  many  cases 
when  the  general  symptoms  of  calcarea  are  present  with  en- 
largement of  the  cervical  glands.  The  lower  attenuations 
should  be  used. 

Hepar  Sidph.—ls  adapted  to  phlyctenular  inflammation  oc- 
curring  after  measles,  or  in  strumous  children,  where  there  is 
intense  photophobia,  lachrymation,  an  injection  of  the  con- 
junctiva  with  swelling  of  the  lids,  sensitiveness  to  touch  and  a 
desire  to  have  them  covered,  and  when  the  external  canthi 
bleed  easily  on  opening  them.  _ 

Arsenicum.— CdiSQS  occurring  in  thin,  ill-nourished  children, 


86  THE  DISEASES  OF  CHILDREN. 

without  marked  inflammatory  symptoms.  There  is  usually 
intense  photophobia,  and  profuse,  acrid  lachrymation.  The 
phlyctenules  tend  to  form  ulcers  which  extend  superficially 
and  take  on  an  indolent  character. 

Rhus  Tox. — Where  there  is  excessive  photophobia,  lachryma- 
tion and  spasmodic  closure  of  the  lids.  There  is  generally  a 
vesicular  or  pustular  eruption  upon  the  eyelids  or  face.  Antim. 
tart.,  ipec,  kali.bi.,  mez.,  crot.  tig.,  euphrasia,  sepia,  and 
baryta,  are  also  serviceable  in  phlyctenular  conjunctivitis  and 
will  give  prompt  results  when  indicated. 

Ulcers  of  the  Cornea  are  of  frequent  occurrence  among 
children,  but  less  so  among  infants.  The  most  simple  form 
of  ulceration  of  the  cornea  is  that  exhibited  by  a  grayish- 
white  spot  which  is  usually  located  at  the  center  of  the  cornea. 
It  is  often  not  examined  early  enough  to  show  its  flattened 
conical  elevation  presented  in  the  first  stage,  the  later  develop- 
ment exhibiting  a  slight  depression  of  the  cornea  with  perhaps 
little  of  the  grayish  infiltration  which  marked  its  beginning. 

The  photophobia,  congestion  of  the  eye  and  swelling  of  the 
lids,  are  variable  symptoms  which  also  seem  to  bear  by  their 
intensity  no  ratio  to  the  duration  or  extent  of  the  ulcer. 

As  these  ulcers  commonly  attack  the  central  portion  of  the 
cornea,  their  danger  to  vision  is  great,  as  they  usually  attack 
one  eye  at  a  time,  and  tend  to  recur  in  the  same  or  the  other 
eye.  The  opacity  or  scar  thus  left  is  greater  in  those  cases 
where  the  repeated  ulceration  has  caused  the  greater  loss  of 
transparency.  The  central  location  of  the  opacity  causes  such 
a  marked  interference  with  the  function  of  vision  in  many  cases 
as  to  destroy  the  sight  entirely.  In  cases  where  the  ulceration 
is  acute  in  its  course  and  heals  rapidly,  the  destruction  of  tissue 
and  loss  of  transparency  is  much  less  than  in  those  which  pre- 
sent a  chronic  and  recurrent  character.  In  some  cases  the 
repair  of  the  lost  substance  is  not  completed  and  a  flattening  of 
the  curve  of  the  cornea  occurs  at  the  site  of  ulceration  which 
interferes  greatly  with  the  vision. 

It  should  be  borne  in  mind  that  these  ulcers  now  and  then 
tend  to  spread,  and  take  on  a  suppurative  character,  when  this 
occurs  the  danger  becomes  very  great.  The  original  infiltra- 
tion sometimes  passes  rapidly  to  the  formation  of  an  abscess 
of  the  cornea,  with  extensive  destruction  of  tissue  and  loss  of 
the  eye.  When  an  abscess  is  forming,  a  small  spot  slightly 
raised  appears,  accompanied  by  much  pain  and  congestion.  It 
enlarges  rapidly,  becomes  yellow  in  color  and  commonly  rup- 
tures outward,  leaving  a  more  or  less  deep,  round  ulceration 
with  a  yellowish,  purulent  infiltration,  which  may  ultimately 


PHLTCTENULAR   ULCERS.  87 

destroy  the  cornea.  Sometimes  the  abscess  may  open  into  the 
anterior  chamber,  and  hypopyon,  a  collection  of  pus  in  this  part 
of  the  eye,  results. 

The  causes  which  give  rise  to  these  destructive  attacks  are, 
in  my  opinion,  invariably  those  due  to  malnutrition,  defective 
nourishment,  and  a  strumous  habit,  with  bad  hygienic  sur- 
roundings. 

Phlyctenular  Ulcers  (phlyctenular  keratitis,  pustular 
ophthalmia,  marginal  keratitis,  strumous  or  scrofulous  oph- 
thalmia) constitute  the  larger  number  of  ulcerations  of  the 
cornea  occurring  during  childhood. 

The  causes  which  give  rise  to  them  are  the  same  as  those 
which  have  already  been  indicated  as  producing  the  central 
ulcerations. 

The  symptoms  are  first,  photophobia,  that  one  which  is  usu- 
ally most  marked  and  which  is  common  to  all  corneal  inflam- 
mations or  ulcerations.  The  dread  of  the  light  varies  with  the 
development  of  the  phlyctenule  or  pustule  upon  the  cornea, 
being  often  slight  in  the  first  stage  and  moderate  later,  or  in- 
tense to  a  degree  that  there  is  no  place  sufficiently  dark  to  en- 
able the  child  to  open  its  eyes. 

This  over-sensitiveness  to  light  causes,  as  a  reflex,  a  marked 
spasmodic  closing  of  the  lids.  The  blepharospasm  is  often  one 
of  the  most  painful  and  most  annoying  of  the  symptoms  which 
occur  in  this  disease.  The  child  is  inclined  to  lie  with  its  face 
buried  in  the  pillow,  or  the  lap  of  the  mother,  or  seek  the  dark- 
est corner  of  the  room  and  cover  the  eyes  with  the  hands. 

A  pustular  eruption  is  often  present  on  the  face  and  lids. 
The  constant  discharge  of  mucus  from  the  nose,  owing  to  the 
irritating  qualities  of  the  secretion  from  the  eyes  which  passes 
into  the  nose,  gives  rise  to  the  common  idea  that  the  child  is 
suffering  from  a  cold  in  the  head. 

If  the  lids  are  separated,  and  it  often  requires  considerable 
force  upon  the  part  of  the  examiner  to  do  so  (unless  he  has 
instilled  a  drop  of  a  2-per-cent.  solution  of  cocaine  at  intervals 
of  two  or  three  minutes  for  two  or  three  times),  we  find  per- 
haps only  a  single  spot  upon  the  cornea  with  a  triangular- 
shaped  injection  of  blood-vessels  radiating  from  it.  There  may, 
however,  be  several  of  these  phlyctenules  situated  upon  differ- 
■ent  portions  of  the  cornea  or  arranged  in  ring-shape  at  the 
margin  of  the  cornea,  often  encircling  its  whole  periphery. 
These  pustules  vary  in  size  from  a  small  point  to  those  of  two 
or  three  millimeters  in  diameter.  They  are  due  to  exudation 
of  serum  beneath  the  epithelial  layers  of  the  cornea  and  usu- 
ally about  the  terminal  filaments  of  the  branches  of  the  fifth 


88  THE  DISEASES  OF  CHILDREN. 

nerve  which  supply  it.  The  phlyctenule,  bleb  or  pustule  thus 
formed  by  the  exudation  is  raised  above  the  surface  of  the  cor- 
nea, and  contains  within  its  cavity  serum,  a  few  leucocytes, 
or  some  white  corpuscles.  Its  top  may  appear  yellow,  but 
more  often  when  seen  the  surface  is  abraded  and  it  has  a  gray- 
ish and  aphthous  look.  The  eruption  may  be  resolved  without 
breaking  down  in  some  cases,  but  the  majority  rupture  and 
ulcers  result.  The  rupture  is  followed  by  rapid  healing  in 
some  cases.  More  frequently,  however,  the  ulcer  takes  on  a 
sluggish  condition  and  becomes  a  source  of  much  discomfort  to 
the  child  and  danger  to  its  vision. 

The  congestion  of  the  eyeball  and  cornea  as  well  as  the  pain 
vary  extremely  in  degree  in  different  cases,  the  congestion 
being  usually  confined  to  that  part  of  the  sclera  immediately 
surrounding  the  cornea,  but  may  involve  the  whole  of  the  sclera 
as  well. 

The  pain  is  usually  referred  to  the  parts  about  the  eye  in 
those  cases  when  the  child  is  old  enough  to  describe  it,  or  in- 
volves the  whole  head  when  there  is  great  photophobia  and  the 
eyes  are  exposed  to  the  light. 

Treatment  should  consist,  first,  in  the  attempt  to  correct 
the  nutrition  by  regulation  of  diet,  the  increase  of  the  nour- 
ishment by  the  addition  of  those  condensed  foods  which  are 
now  so  well  prepared  and  which  are  usually  readily  digested 
and  assimilated.  My  preference  in  those  cases  has  been  for 
those  that  are  made  from  beef.  Murdock's  Food,  Bovinine 
and  certain  of  the  beef  extracts  are  of  the  greatest  value 
in  supplying  to  the  blood  those  elements  which  are  so  neces- 
sary for  the  protection  of  the  cornea,  which  derives  its  nourish- 
ment only  indirectly  from  the  blood-vessels,  so  that  if  the  blood 
is  not  in  a  well-nourished  state,  by  the  time  it  reaches,  in  its 
diluted  condition,  the  central  portion  of  the  cornea,  there  is  not 
enough  nourishment  in  it  to  maintain  the  vitality  of  the  part 
and  the  ulceration  and  destruction  begin. 

Second,  in  the  effort  to  accomplish  an  early  repair  of  the 
ulceration  by  such  local  applications  and  measures  as  may  be 
deemed  expedient.  Among  the  possible  aids  in  this  direction 
may  be  mentioned  the  probable  necessity  of  keeping  the  eye 
quiet  by  bandaging  in  the  effort  to  hasten  the  healing  process. 
As  a  rule,  I  do  not  advise  the  bandaging  of  the  eyes  of  very 
young  children  except  in  special  cases,  as  its  good  results  depend 
much  upon  the  judgment  and  experience  of  the  medical  attend- 
ant in  these  cases.  In  childhood  and  youth  the  bandage  is 
likely  to  do  more  good  and  less  harm  than  in  infancy.  The 
objection  to  close  bandaging  is  due  to  the  confinement  of  the 
secretions,  often  acrid,  within  the  eye,  which   thus   increases 


PHLYCTENULAR   ULCERS— TREATMENT.  89 

rather  than  diminishes  the  inflammatory  process  and  the  ina- 
bility of  the  attendant  to  properly  readjust  the  bandage  when  its 
removal  may  be  so  often  necessary  for  the  purpose  of  instilling 
the  collyrium  (boracic  acid  grs.  viii.  to/ji.)  which  is  intended 
to  lessen  the  irritation  arising  from  the  increased  or  changed 
secretion,  or  the  application  of  lotions  (chlorine  water  diluted 
one  half,  saturated  solution  of  boracic  acid,  or  bi-chloride  sol. 
I  to  lom),  intended  to  act  as  germicides  and  thus  lessen  the 
danger  of  further  infective  extension  of  the  ulcerative  process. 

Third,  to  stimulate  the  healing  of  the  ulcers,  especially  in 
those  indolent  cases  which  cause  all  so  much  anxiety,  by  such 
applications  as  calomel,  finely  divided  flowers  of  sulphur, 
which  are  gently  dusted  upon  the  ulceration,  or  the  use  of  a 
minute  portion  of  an  ointment  made  of  cosmoHne,  5  i  ad  grs.  ii. 
hydrg-ox-flav.,  which  is  introduced  between  the  lids  and  rubbed 
upon  the  eyeball. 

Fourth,  to  relieve  the  photophobia  by  the  use  of  smoke- 
tinted  goggles  or  in  less  severe  cases  the  visor-eye-shade  may 
enable  the  child  to  get  that  stimulus  from  light,  fresh  air  and 
exercise  that  it  most  needs  and  without  detriment  to  its  eyes. 
The  pain  should  be  relieved  as  far  as  may  be  possible  by  the 
occasional  use  of  atropine  solution  (3^  gr.  to  2  gr.  to  the/gi.), 
when  the  ciliary  congestion  is  marked,  or  much  relief  may 
be  obtained  from  hydro-chlorate  of  cocaine  (2  per  cent.  sol.  a 
drop  once  or  twice  a  day). 

Fifth,  benefit  sometimes  follows  the  application  of  hot  fomen- 
tations or  poultices  ;  the  latter,  however,  should  never  be  applied 
except  when  directed  by  the  ophthalmic  surgeon,  as  their  use 
is  more  likely  to  do  harm  than  good ;  poultices  being  usually 
indicated  only  in  those  cases  where  the  cornea  presents  an 
abscess  of  consideratable  extent,  a  suppurative  ulceration,  caus- 
ing rapid  destruction  or  a  necrotic  condition  is  imminent.  In 
some  cases  it  may  be  necessary  to  apply  the  electric  cautery  in 
the  effort  to  limit  the  destructive  process.  In  all  cases  where 
the  physician  is  in  doubt  about  the  necessity  for,  or  the  value 
of  topical  applications  which  in  his  judgment  might  be  detri- 
mental, it  is  better  to  await  for  a  day  or  two  the  result  of  the 
internal  medicines  which  he  has  prescribed,  as  in  some  of  these 
severe  cases,  it  is  impossible  for  those  who  are  skilled  by  judg- 
ment and  experience  to  advise  with  certainty  those  local 
measures  which  may  be  best  in  certain  cases. 

The  internal  medications  necessary  for  the  cure  of  these 
ulcerations  of  the  cornea  of  children,  have  a  more  reaching 
effect  than  the  local  measures  mentioned  and  are  more  rapid 
in  their  action  in  controlling  and  limiting  their  destructive 
influences. 


90  THE  DISEASES  OF  CHILDREN. 

REMEDIES. 

Aconite. — Superficial  ulcers  arising  from  injuries.  It  maybe 
used  both  internally  and  externally. 

Arsenicum. — Corneal  ulcers  occurring  in  weak,  anaemic  chil- 
dren. They  are  often  superficial  and  have  a  tendency  to  recur. 
The  photophobia  is  excessive  and  the  lachrymation  acrid  and 
burning.  The  pains  are  more  frequently  burning  and  aggra- 
vated after  midnight.  Small  grayish  central  ulcers  which 
occur  in  young  children  and  tend  to  perforate. 

Aurum. — Vascular  ulceration  of  the  cornea  and  ulcera- 
tions occurring  during  the  course  of  pannus,  or  as  the  result  of 
abscess.  There  is  much  photophobia,  profuse  scalding  lachry- 
mation and  sensitiveness  of  the  eye  to  touch,  and  pains  appar- 
ently extending  from  the  parts  around  the  eye  to  the  eye,  and 
aggravated  by  touch. 

Calc.  Carb.  and  Calc.  Hypophos. — Ulcerations  occurring  in 
ill-nourished  patients  which  show  a  tendency  to  slough,  or 
which  result  from  abscess. 

Conium. — Some  superficial  ulcers  without  much  pain  or  red- 
ness, but  with  intense  photophobia. 

Graphites. — In  some  cases  of  ulceration  of  the  cornea  which 
have  followed  attacks  of  phlyctenular  inflammation  of  the 
cornea  or  conjunctiva. 

Hepar  Sulphur. — A  valuable  remedy  for  all  ulcers  or  ab- 
scesses where  there  is  pus  in  the  anterior  chamber.  There  is 
usually  a  marked  sloughing  tendency  and  the  pain  is  throbbing 
and  the  photophobia  intense,  while  the  conjunctiva  is  often 
red  and  thickened  or  chemosed.  There  is  relief  generally  from 
bandaging  the  eye  and  the  application  of  warm  compresses, 
although  there  is  great  sensitiveness  of  the  eye  to  touch. 

Ignatia. — Small  chipping  ulcers  without  much  discomfort, 
which  occur  in  connection  with  derangements  of  the  digestion  ; 
also  small  pinhole  ulcers,  which  are  attended  by  photophobia 
and  sensation  as  if  something  was  in  the  eye,  in  nervous  and 
hysterical  patients. 

Mercurius. — Often  indicated  in  both  superficial  and  deep 
ulcerations.  There  is  generally  grayish  infiltration  of  the  base 
and  around  the  ulcer,  which  is  also  often  vascular.  The  discharges 
from  the  eye  are  profuse,  thin  and  excoriating.  There  is  a 
general  aggravation  at  night.  Concomitant  symptoms  more 
frequently  decide  upon  the  particular  form  of  mercury  to  be 
administered  ;  the  eye  symptoms  indicating  mere.  cor.  being 
more  intense  and  there  is  much  ciliary  injection  and  pain. 

Merc.  Nit. — More  useful  in  those  ulcerations  which  partake 
of  a  phlyctenular  character. 


DIFFUSE  KERATITIS.  91 

Merc.  Prot. — Ulcerations  occurring  with  pannus ;  its  efficacy 
in  ulcus  serpens  is  very  doubtful  and  it  has  not  proved  as  use- 
ful as  calc.  phos.  or  silicia  in  these  cases. 

Nux  Vomica  and  Pulsatilla  suit  some  cases  of  superficial 
ulcerations  with  intense  photophobia,  and  it  becomes  very  dif- 
ficult  to  differentiate  between  them  when  marked  concomitant 
symptoms  are  not  present. 

Silicia. — Indicated  in  some  cases  of  sloughing  ulcers  of  the 
cornea,  as  in  the  marginal  ulcer,  and  when  small,  funnel-shaped 
non-vascular  ulcers  appear  near  the  center  of  the  cornea  and 
rapidly  perforate. 

Sulphur. — When  the  ulceration  is  indolent  and  tends  to 
slough  this  remedy  will  be  useful.  There  is  often  considerable 
infiltration  around  the  ulcer,  but  no  vascularity.  The  photo- 
phobia, lachrymation  and  other  symptoms  are  variable.  The 
sharp,  sticking  pains,  which  are  commonly  present  and  worse 
after  midnight,  are  very  characteristic.  The  subjects  are 
strumous  and  the  general  condition  is  indicative  of  sulphur. 
Many  other  remedies  may  have  to  be  consulted  for  individual 
cases. 

Diffuse  Keratitis  (syphilitic,  interstitial,  parenchyma- 
tous, strumous  or  scrofulous  keratitis),  is  an  inflammation  of  the 
cornea  which  essentially  is  a  disease  of  childhood.  It  occurs 
commonly  between  the  ages  of  five  and  twelve,  some  cases  being 
reported  between  the  second  and  third  year,  and  very  rarely  later 
than  the  fifteenth  year,  and  still  much  more  rare  in  adult  life. 

Etiology. — Inherited  syphilis  is  the  undoubted  cause  of 
this  disease,  and  in  children  in  which  it  presents  itself  we  have 
the  physiognomy,  notched  teeth,  skin,  mouth  and  bones  which 
we  have  learned  to  regard  as  positive  indications  of  syphilitic 
inheritance.  In  the  absence  of  these  signs,  we  may  have  to  as- 
sign as  the  cause  a  scrofulous  or  strumous  habit ;  or  with  other 
symptoms  it  may  be  coincident  with  the  secondary  stage  of 
acquired  syphilis,  the  latter,  however,  being  extremely  rare. 

Symptoms. — A  grayish  opacity  first  shows  itself  at  the  center 
of  the  cornea  in  the  tissue,  and  gradually  extends  with  increas- 
ing density,  until  the  whole  cornea  has  lost  its  transparency. 
Again,  the  opacity  may  begin  at  one  or  more  places  near  the 
margin  of  the  cornea  and  extend  to  the  center.  These  changes 
in  the  cornea  which  mark  the  beginning  of  a  chronic  inflamma- 
tion of  its  tissue,  and  which  does  not  go  on  to  ulceration  or  ab- 
scess, are  ushered  in  by  a  preliminary  stage,  often  overlooked. 
•»c  of  injection  of  the  sclera  about  the  margin  of  the  cornea,  and  a 
watery  appearance  of  the  eye  from  increased  lachrymation. 
The  sight  is  rapidly  lost,  and  if  the  disease  attacks  both  cor- 


92  THE  DISEASES  OF  CHILDREN. 

neas,  as  may  be  the  case,  though  usually  the  disease  is  well 
advanced  in  one  before  the  other  is  affected,  the  first  symptom 
noticed  in  young  children  is  the  falls  the  child  suffers  from, 
owing  to  its  imperfect  vision. 

It  is  rare  that  more  than  a  few  months  intervenes  before  the 
second  eye  is  attacked,  and  extremely  rare  that  a  year  or  more 
elapses,  as  the  disease  is  commonly  symmetrical. 

In  from  two  to  four  weeks  the  cornea  becomes  so  opaque 
that  the  iris  and  pupil  are  no  longer  seen,  and  the  grayish- 
white  appearance  looks  like  ground  or  frosted  glass,  its  surface 
roughened  from  the  loss  of  portions  of  its  epithelium.  An  in- 
flammation of  the  iris  often  complicates  the  attack,  and  by 
adherence  to  the  lens  capsule  (posterior  synechia),  lessens  the 
recovery  of  vision,  as  well  as  increasing  the  discomfort  of  the 
sufferer.  The  pain,  if  the  iris  does  not  become  involved,  is  not 
marked,  and  the  dread  of  light  is  perhaps  less  marked  in  this, 
than  any  other  disease  of  the  cornea. 

The  opacity,  on  close  examination,  is  found  in  many  cases 
to  be  of  unequal  density,  or  may  present  a  reddish  color  due 
to  the  development  of  blood-vessels  in  the  layers  of  the  cornea. 
This  vascularity  may  involve  the  whole  or  only  portions  of  the 
cornea,  and  may  be  regarded  as  an  indication  of  a  more  serious 
attack  than  when  absent. 

Prognosis. — The  duration  of  the  attack  is  prolonged  from 
six  months  to  two  years,  and  when  the  diagnosis  is  made,  the 
parents  of  the  child  should  be  informed  of  the  probable  time  ta 
be  consumed  in  the  development  of  the  various  stages,  and 
that  the  ultimate  recovery  is  reasonably  sure.  While  the  prog- 
nosis as  regards  the  vision  is  good,  the  cornea  rarely  recovers 
its  perfect  transparency.  Relapses  are  not  infrequent,  and  com- 
plications of  the  iris,  choroid,  retina  and  glaucoma  may  occur^ 
rendering  the  prognosis  more  grave. 

Treatment. — Homeopathic  remedies  have  the  power,  when 
properly  used,  to  lessen  not  only  the  severity  of  the  attack 
and  mitigate  its  symptoms,  but  also  to  shorten  its  duration 
in  a  remarkable  manner. 

No  local  applications,  except  that  of  atropine  in  cases  of  iritic 
complications,  or  the  occasional  use  of  cocaine  for  temporary  an- 
esthetic purposes,  are  advisable,  as  indeed  all  others  are  harm- 
ful. In  rare  cases  hot  compresses  may  be  of  value,  but  should 
only  be  applied  under  skillful  direction. 

As  these  patients  are  often  anaemic  or  present  indications  of 
impaired  nutrition,  particular  attention  must  be  given  to  proper 
feeding  or  necessary  stimulation. 

The  indications  for  the  remedies  should  be  carefully  studied; 
these  given  here  constitute  the  ones  more  frequently  needed. 


OPACITIES  OF  THE  CORNEA.  93 

REMEDIES. 

Aurum  Mur. — This  preparation  is  one  of  the  most  frequently 
indicated  in  cases  of  syphilitic  keratitis.  The  symptoms  are 
those  of  diffuse  infiltration  with  moderate  photophobia,  and 
pain  which  is  of  a  dull  character  and  referred  to  the  parts  about 
the  eye. 

Mercurius  Sol. — The  inflammation  is  more  active ;  there  is 
usually  more  pain,  greater  ciliary  injection  and  nocturnal  ag- 
gravation than  under  aurum,  and  the  general  concomitants  of 
mercury  are  present. 

Mercurius  Prot. — Often  useful  when  mere.  sol.  does  not  act 
promptly. 

Arsenicum. — Diffuse  keratitis  with  marginal  vascularity.  The 
photophobia  is  intense,  the  lachrymation  profuse,  and  burning 
pains  are  complained  of.  The  aggravation  after  midnight,  rest- 
lessness and  thirst  are  commonly  present. 

Apis  il/^/.— With  the  infiltration  of  the  cornea  there  is  mod- 
erate injection  of  the  ciliary  region  and  photophobia.  Febrile 
disturbance,  thirst,  and  drowsiness  often  accompany  the  con- 
dition. 

Hepar  Sulphur. — Often  serviceable  when  there  is  much  ciliary 
injection  or  pain,  great  photophobia,  lachrymation  and  sensi- 
tiveness of  the  eye  to  the  touch. 

Baryta  lod. — When  enlargement  of  the  cervical  glands,  which 
are  hard  and  painful  on  pressure,  accompany  the  diseases  of  the 
cornea. 

Kali  Mur. — Interstitial  keratitis  with  occasional  pain,  mod- 
erate photophobia  and  redness. 

Opacities  of  the  Cornea,  resulting  from  the  various  in- 
flammatory affections  of  the  cornea,  are  termed  leucoma,  ma- 
cula, and  nebula  according  to  the  density  of  the  scar,  the  former 
being  the  most  dense.  When  their  location  is  not  central  the 
vision  may  not  be  affected,  but  when  located  over  the  pupil  the 
vision  is  destroyed  in  proportion  to  the  thickness  of  the  opacity. 

In  children  the  prospect  of  gradual  absorption  is  good,  but  it 
is  rare  that  the  vision  becomes  as  good  as  it  was  before  the  af- 
fection, which  caused  its  appearance,  occurred.  The  lessening 
of  the  opacity  as  the  child  grows  older  lessens  the  cosmetic  de- 
fect of  the  eye,  even  if  the  vision  is  not  impaired.  When  these 
opacities  are  central  and  occur  in  both  eyes,  they  give  rise  to 
nystagmus,  that  oscillating,  restless  movement  of  the  eyes 
which  occurs  when,  owing  to  the  impairment  of  its  central  vision, 
the  child  endeavors  to  fix  the  eyes  upon  the  object  so  that  a 
better  image  may  be  obtained  through  the  more  transparent 


94  THE  DISEASES  OF  CHILDREN. 

portions  of  the  cornea.  In  cases  where  it  is  bilateral,  diver- 
gent squint  occurs,  or  when  unilateral  it  may  be  a  cause  of. 
convergent  squint. 

The  treatment  consists  of  the  use  of  such  homeopathic  reme- 
dies as  hepar  sulph.,  calc.  carb.,  silicea  and  sulphur,  which  in 
some  cases  exhibit  a  marked  influence  in  occasioning  rapidity 
of  tissue  change  after  inflammatory  processes.  In  addition  cer- 
tain drugs,  which,  when  applied  to  the  scar,  occasion  a  tempo- 
rary congestion  or  mild  inflammation  and  hasten  its  clearing, 
mere,  nit.,  boracic  acid  powder,  sulphate  of  soda  or  resorcin, 
when  applied  by  means  of  a  small  swab  of  cotton,  giving  the 
best  results. 

When  both  eyes  present  a  central  opacity,  or  the  vision  only 
resides  in  the  one  affected  by  the  scar,  a  new  pupil  should  be 
formed  by  making  an  iridectomy  in  the  direction  of  the  most 
transparent  portion  of  the  cornea  remaining. 

When  in  older  children  or  adults  the  leucoma  is  a  source  of 
great  disfigurement,  it  may  be  tattooed  with  india  ink. 

Staphyloma  of  the  cornea,  a  bulging  projection  of  the  cor- 
nea which  occurs  frequently  in  children,  results  from  either 
perforation  of  the  cornea  and  prolapse  of  the  iris  following  ul- 
ceration in  purulent  forms  of  conjunctivitis,  or  from  the  soften- 
ing of  the  corneal  tissue  which  accompanies  some  cases  of 
chronic  phlyctenular  inflammations  with  increased  fluid  pres- 
sure within  the  eye. 

If  the  bulging  involves  the  whole  of  the  cornea,  it  is  apt  to 
continue  until  it  becomes  a  serious  deformity  and  protrudes 
between  the  lids,  notwithstanding  our  efforts  to  lessen  the  ten- 
sion by  frequent  tappings  of  the  anterior  chamber  (paracentesis 
corneae),  or  the  removal  of  a  portion  of  the  iris  (iridectomy). 
When  it  is  complete,  and  subjected  to  irritation,  inflammation 
of  the  ball  occurs  and  it  becomes  necessary  to  remove  the 
projecting  portion  (abscission)  or  remove  the  eyeball  (enucle- 
ation). 

Blepharitis  Marginalis  (ophthalmia  tarsi,  tinea  tarsi, 
acne  ciliaris,  blepharo  adenitis),  the  free  margins  of  the  eyelids 
containing  the  meibomian  glands,  the  cilia,  sebaceous  and 
modified  perspiratory  glands  are  liable  to  acute  and  chronic  in- 
flammation in  infancy  and  childhood.  With  the  terminal  cir- 
culation of  the  blood  supply  at  their  borders,  the  high  develop- 
ment of  glandular  structure  within  them  and  transition  from 
skin  to  mucous  membrane  which  occurs  at  their  movable  edges, 
are  presented  anatomical  conditions  which  may  readily  acquire 
a  pathological  state  by  inflammatory  changes  due  to  heredity. 


BLEPHARITIS  MARGINALIS.  95 

impoverished  blood,  external  irritation,  or  reflex  eye  strain  due 
to  errors  of  refraction. 

Various  types  of  the  disease  may  be  described  and  the  dis- 
ease may  affect  both  lids  of  the  eyes,  or  only  a  single  lid  or 
part  of  it. 

In  the  more  simple  cases  an  incrustation  about  the  base  of 
the  cilia,  resulting  in  a  pyramidical  or  conical  formation  from 
an  increased  secretion  from  the  sebaceous  glands  at  the  roots 
of  the  eyelashes  presents  the  condition  which  is  distinguished 
often  by  the  laity  as  "  granular  lids,"  a  misnomer  always. 

Some  cases  may  present  only  a  superficial  eczema,  character- 
ized by  slight  redness,  with  dry  or  moist  scales  which  form 
upon  the  lid-edges,  but  do  not  form  masses  clinging  to  the  eye- 
lashes, as  in  the  former  type.  These  types  may  soon  lose  the 
simplicity  by  the  lid-border  becoming  red,  the  glands  and  eye- 
lash follicles  inflaming  and  the  lid-margin  thickening,  yellow 
points  due  to  purulent  infiltration  present  themselves,  ulcera- 
tion more  or  less  deep  of  the  lid-margins  follows.  The  chronic 
process  set  up  in  the  appendages  of  the  eye,  results  in  the  loss 
of  the  cilia,  the  destruction  of  the  Hd-margins  or  their  deform- 
ity. The  cosmetic  defect  produced  by  the  ravages  of  this  dis- 
ease is  perhaps  more  readily  noticed  than  that  of  diseases  of 
the  eyeball  which  destroy  its  beauty  or  the  function  of  sight. 

Etiology. — This  affection  of  the  eyelids  begins  often  early 
in  childhood  and  infancy,  and  is  due  either  to  heredity,  malnu- 
trition, or  follows  as  a  sequela  of  the  eruptive  fevers,  of  the 
latter,  measles  perhaps  furnishing  more  commonly  the  excit- 
ing cause.  Chronic  catarrhal  affections  of  the  conjunctiva  and 
lachrymal  sac  both  cause  and  complicate  this  disease.  Bad 
hygienic  surroundings,  the  exposure  to  wind,  dust,  impure  at- 
mosphere, as  in  crowded  tenements,  should  also  be  mentioned 
as  exciting  causes. 

Treatment. — In  both  the  simple  and  severe  cases  the  local 
treatment  demands  the  removal  of  the  masses  which  form  upon 
the  cilia,  which  while  they  remain,  tend  to  increase  by  their 
irritation  the  inflammation  of  the  lids.  This  is  not  so  readily 
done  as  might  be  supposed,  as  the  crusts  thus  formed  are  hard, 
not  readily  soluble,  and  their  mechanical  removal  often  pain- 
ful, and  particularly  so  when  the  eyelashes  are  removed  with 
them. 

For  the  removal  of  these  masses  the  lids  should  be  bathed 
in  warm  water  in  which  a  little  bicarbonate  of  soda  or  borax 
has  been  dissolved,  and  as  soon  as  the  crusts  have  been  mois- 
tened they  are  removed  by  drawing  the  cilia  through  the  thumb 
and  forefinger,  or  picked  from  the  lashes  by  the  aid  of  a  pair  of 
forceps.     These  crusts  once  thoroughly  removed,  the  free  mar- 


96  THE  DISEASES  OF  CHILDREN. 

gins  of  the  lids  should  be  smeared  with  vaseline  or  cosmoline 
in  their  plain  forms,  or  in  combination  with  mercury  or  graph- 
ites in  the  form  of  an  ointment.  The  use  of  these  prepara- 
tions hastens  the  recovery  by  lessening  the  irritation  of  the 
inflamed  lid,  and  by  their  specific  remedial  effect  when  thus 
applied.  The  effort  should  be  made  to  have  the  accumulations 
upon  the  lid-edges  removed  as  rapidly  as  they  form  to  prevent 
the  increased  irritation  caused  by  their  presence. 

When  blepharitis  does  not  respond  promptly  to  treatment, 
the  refraction  of  the  eye  must  be  examined,  and  when  found 
affected,  glasses  which  properly  correct  the  ametropia  must  be 
worn  constantly. 

Occasionally  the  presence  of  lice  {Phthiriasis  ciliaruni)  upon 
the  lashes  simulates  blepharitis  or  causes  it.  The  lice  are  to 
be  picked  off,  the  nit  which  clings  to  the  cilia  destroyed,  and 
the  lid-margins  anointed  with  mercurial  ointment  to  prevent 
their  redevelopment, 

REMEDIES. 

Aconite. — Indicated  in  an  acute  attack,  but  such  cases  are 
extremely  rare,  and  when  occurring,  result  from  exposure  of 
the  eyes  to  dry  cold  winds  during  long  drives.  The  lid-margins 
are  swollen,  hot  and  dry,  and  there  is  more  or  less  inflamma- 
tion of  the  conjunctiva  accompanying  it. 

Graphites. — The  action  upon  the  edges  of  the  lid  is  very 
marked,  and  is  perhaps  the  most  useful  remedy  we  possess  for 
the  chronic  form  of  blepharitis,  particularly  when  occurring  in 
strumous  subjects  and  accompanied  by  the  moist,  fissured  and 
easily  bleeding,  eczematous  eruptions  on  the  cheeks  or  behind 
the  ears,  which  are  so  promptly  cured  by  this  remedy.  The 
swelling  of  the  margins  of  the  lids  is  variable,  in  color  pale  red, 
and  crusted  with  dry  scabs  which  cover  spots  of  ulceration,  or 
numerous  fine  scales  are  found  on  the  skin  and  among  the  cilia, 
which  can  be  brushed  off.  There  is  much  itching,  burning  and 
biting  of  the  lids  which  the  patient  tries  to  relieve  by  rubbing, 
but  this  only  aggravates  the  trouble.  In  many  cases  there  is  a 
fissured  condition  of  the  skin  of  the  outer  canthus,  which  bleeds 
readily  from  rubbing  or  opening  the  eyelids.  The  cure  is 
hastened  by  the  application  of  the  graphites  ointment  to  the 
lids  at  night. 

Mercurius. — The  various  forms  of  mercury  are  extremely 
useful  in  blepharitis,  the  mere.  sol.  or  vivus  more  frequently 
perhaps  than  the  others.  The  lids  are  much  thickened,  red, 
and  often  ulcerated,  with  sensitiveness  to  touch,  heat  and  cold. 
The  lid  conjunctiva  is  hyperemic,  or  inflamed,  with  an  acrid 
lachrymation  which  increases  the  irritation  of  the  lids.     There 


BLEPHARITIS  MARGIN ALIS— REMEDIES.  97 

is  an  aggravation  of  the  whole  condition  from  exposure  to 
the  light  and  heat  of  fires,  or  in  the  evening  from  artificial 
light.  The  local  application  of  an  ointment  containing  grs.  ii 
of  the  mere,  precip.  alb.  or  the  mere.  iod.  fiav.  to  i3  of  vaseline 
will  be  found  very  useful. 

Merc.  cor.  and  prot.  present  similar  symptoms,  but  in  a  more 
marked  degree  and  where  there  is  a  pustular  eruption  on  the 
parts  about  the  eye  or  upon  the  conjunctiva.  The  prescription 
must  be  based  upon  a  careful  consideration  of  the  circum- 
stances and  symptoms  as  well. 

Sulphur. — Suitable  in  a  large  number  of  cases  occurring  in 
scrofulous  children  where  the  disease  is  occasioned  by  the 
debility  following  the  exanthematous  diseases,  or  appears  as  the 
accompaniment  of  eczema  of  the  face  or  head,  for  which  sul- 
phur would  be  indicated.  The  lids  are  red,  swollen,  with  nu- 
merous small  points  of  suppuration,  or  are  ulcerated  along  the 
edges.  The  characteristic  pains  are  fine,  sharp  and  sticking, 
though  itching,  biting,  burning  and  many  other  sensations  may 
be  present.  There  is  usually  an  aggravation  from  wet  applica- 
tions to  the  parts  as  well  as  a  general  aversion  to  being  washed. 

Pulsatilla. — In  cases  arising  from  some  gastric  derangement 
dependent  upon  consumption  of  fat  foods,  there  is  a  great 
tendency  to  the  formation  of  styes,  and  frequently  acne  of  the 
face.  The  swelling  and  redness  of  the  lids  may  vary,  though 
there  is  usually  a  rather  profuse,  bland  discharge  which  agglu- 
tinates the  lids  during  the  night.  Itching  and  burning  are 
complained  of,  with  a  general  evening  aggravation  and  from  a- 
close  or  warm  atmosphere,  with  relief  from  fresh  cold  air. 

Arsenicum. — Blepharitis  occurring  in  cases  where  the  general 
condition  presents  debility,  restlessness,  thirst,  night  aggrava- 
tion, etc.  The  lids  are  often  puffed  and  their  edges  very  red, 
and  excoriated  by  the  acrid  lachrymation  which  is  a  fre- 
quent accompaniment  of  the  condition;  again  the  lids  may  be 
smooth,  red,  and  shed  numerous  scales.  The  pains  are  burning 
in  character. 

Calc.  (7«r^.— Especially  adapted  to  blepharitis  in  fat,  unhealthy, 
children  who  sweat  much  about  the  head.  The  lids  are  swollen, 
edematous  and  red,  with  a  thick,  excoriating,  purulent  dis- 
charge, accompanied  by  great  itching  and  burning  of  the  lid- 
margins,  particulariy  at  the  canthi,  with  aggravation  from  damp 
weather  and  in  the  morning. 

Calc.  Phos.  and  Iod.  are  serviceable  in  strumous  cases  pre- 
senting enlargement  of  the  tonsils  and  cervical  glands,  with  the 
eye  symptoms  of  the  carbonate. 

Hepar  Sulph.—The  lid-margins  are  studded  with  small  ulcers 
which  destroy  the  lid  tissue ;  or  they  are  thick,  inflamed  and 
D.  C— 7 


98  THE  DISEASES  OF  CHILDREN. 

tender  to  touch,  with  small  furunculous  swellings  along  the 
margins  or  in  the  meibomian  glands  ;  eczematous  condition  of 
the  face  or  outer  canthus  of  the  lid  with  cracking  and  bleeding 
on  opening  the  eyes.     (Compare  graphites.) 

Petroleum. — Indicated  in  affections  of  the  lid  when  there  is 
itching  and  dryness,  with  smarting  and  sticking  pains  in  inner 
canthus.  The  skin  of  the  lid  is  often  rough  and  dry,  and 
frequently  accompanied  by  the  occipital  headache  character- 
istic of  petroleum.  The  external  application  of  vaseline  or 
cosmoline  softens  the  skin  and  prevents  the  rapid  formation 
of  the  crusts  and  the  gluing  together  of  the  lids,  and  thus  by 
giving  relief  from  this  annoyance  exerts  a  beneficial  influence. 

Antim  Crud. — Curative  in  cases  occurring  in  children  where 
graphites  seems  indicated,  but  when  administered  gives  no  re- 
sult. The  lids  are  inflamed,  swollen,  moist,  and  there  is  a 
pustular  eruption  upon  the  lids  or  upon  the  face,  with  frequent 
agglutination  and  photophobia  in  the  morning. 

Natrum  Mur. — Useful  where  the  lids  are  inflamed  and 
thickened,  accompanied  by  smarting  and  burning,  with  some 
conjunctival  inflammation  and  a  sensation  of  sand  in  the  eyes. 
The  lachrymation  is  acrid  and  excoriates  the  lids  and  cheeky 
giving  them  the  characteristic  glossy  appearance. 

Rhus  Tox. — Suitable  in  some  cases  where  there  is  heaviness 
and  stiffness  of  the  lids,  or  an  edematous  condition  with  pro- 
fuse lachrymation. 

Sepia. — Scaly  conditions  of  the  lids,  or  small  points  of  pus- 
tular inflammation  at  the  roots  of  the  cilia,  with  a  sensation  as 
if  the  Hds  pressed  too  hard  on  the  eyeball. 

Staphisagria. — Lids  with  dry,  uneven  margins  or  hard  nodules^ 
and  much  itching  and  sensation  of  dryness  of  the  eyes  in  the 
morning. 

Argentum  nit.,  euphrasia,  antim.  tart,  and  mere.  nit.  may  be 
indicated  in  cases  dependent  upon,  or  associated  with,  con- 
junctival disease  ;  other  medicines  may  relieve  when  indicated 
by  the  general  symptoms  of  the  remedy  without  special  refer- 
ence to  the  eye  symptoms. 

Hordeolum,  or  stye,  is  an  acute  inflammation  of  the  cellular 
tissue  of  the  free  border  of  the  lid,  and  appears  close  to  or  in- 
volves one  or  more  cilia.  At  first  a  small  red  and  hard  swelling, 
very  painful  to  touch,  it  soon  causes  much  inflammation  and 
swelling  of  the  part  of  the  lid  in  which  it  is  located  or  of  the 
entire  lid.  It  becomes  developed  in  three  or  four  days,  on  its 
summit  a  yellowish  point  appears  which  usually  ruptures  and 
gives  exit  to  a  little  pus  or  necrosed  cellular  tissue. 

It  is  very  apt  to  recur,  and  children  suffer  from  their  reap- 


CHALAZION— LACHRTMAL  DISEASES.  9<> 

pearance  singly  or  in  groups  for  weeks  and  months.  The 
attacks  are  due  to  either  such  causes  as  general  debility,  indis- 
creet diet  or  the  more  local  one  of  eye  strain  dependent  upon 
errors  of  refraction,  and  irritation  of  the  lids  from  various 
causes. 

The  effort  to  abort  the  stye  is  rarely  successful ;  as  soon  as 
it  is  well  under  way  hot  compresses  are  to  be  applied  to  hasten 
the  formation  of  pus,  which  may  be  evacuated  by  a  slight  in- 
cision or  left  to  break  itself. 

Pulsatilla,  hepar  sulph.,  or  mercurius  at  times  prevent  the  ex- 
tension of  the  inflammation,  but  more  frequently  shorten  the 
course  of  the  attack  and  hasten  resolution.  Graphites,  sulphur, 
calc.  carb.,  staphisagria  and  other  remedies,  when  indicated  by 
the  general  symptoms,  may  prevent  the  recurrence  of  the  styes. 

Chalazion  is  a  small,  firm,  immovable  tumor,  hemispherical 
in  shape,  which  develops  in  the  tarsus  and  arises  from  closure 
of  the  opening  of  a  meibomian  gland  and  the  alteration  of  its 
normal  secretion.  When  it  is  of  spontaneous  origin  it  usually 
disappears  in  a  few  days  without  treatment ;  when,  as  is  usually 
the  case,  its  growth  is  slow,  its  absorption  requires  time.  In 
children  the  causes  which  determine  their  development  are  de- 
fective nutrition,  the  accidental  closure  of  the  mouth  of  one 
of  the  ducts  or  inflammation  or  irritation  of  the  lid-margin. 

The  development  of  the  tumor  may  stop  at  any  stage  and 
remain  stationary  for  an  indefinite  time,  its  size  varying  from 
a  large  pin's  head  to  that  of  a  large  pea,  rarely  developing  be- 
yond this  point. 

The  only  disturbance  arising  from  it,  except  the  unsightly 
appearance  given  by  it  to  the  lid,  is  the  slight  pressure  or  rub- 
bing of  the  eyeball  by  its  internal  projection. 

In  the  majority  of  cases  occurring  in  children  they  are  ab- 
sorbed without  operation,  but  when  necessary  may  be  removed 
by  an  incision  preferably  upon  the  conjunctival  surface  of  the 
lid  and  the  scooping  out  of  the  contents  of  the  cyst. 

Lachrymal  diseases  are  ordinarily  rare  to  the  physician, 
but  less  so  to  the  oculist ;  but  cases  due  to  arrested  develop- 
ment resulting  in  absence  of  the  lachrymal  ducts  are  not  un- 
common. The  overflow  of  tears  which  may  be  noticed  sooner 
or  later  by  the  mother  or  attendants  of  the  infant  indicates  the 
fact  that  the  conduits  have  not  been  developed  or  that  the  nasal 
portion  has  not  been  delivered  of  its  fetal  debris.  If  such  is 
the  case,  suppuration  of  the  lachrymal  sac  of  one  or  both  sides 
takes  place  in  the  infant,  and  its  subjective  redness,  swelling, 
and  the  pain  as  evinced  by  the  child's  restless  discomfort  indi- 


100  THE  DISEASES  OF  CHILDREN. 

cate  to  us  the  location  of  the  lesion,  which  may  require  surgical 
interference  in  the  way  of  incision  to  relieve  the  pressure  aris- 
ing from  the  retention  of  pus.  At  times  the  condition  is  more 
chronic,  and  with  the  prescription  of  the  proper  homeopathic 
remedy  and  perhaps  the  additional  aid  of  some  local  astringent, 
or  a  lotion  of  the  remedy  indicated  for  internal  prescription 
will  often,  when  the  punctum  of  the  canaliculus  is  not  occluded 
or  contracted,  result  in  the  disappearance  of  the  trouble. 

When  the  sac  or  duct  is  congenitally  absent  or  has  been  de- 
stroyed by  injury,  no  relief  can  be  obtained  for  the  persistent 
overflow  of  tears  which  becomes  more  marked  and  annoying  as 
the  child's  years  increase. 

If  the  closure  or  contraction  of  the  punctum  is  the  fault,  then 
it  must  be  opened  and  attention  given  to  the  local  inflamma- 
tion of  the  conjunctiva  resulting  from  the  retention  in  the  con- 
junctival sac,  of  the  secretions  which  should  have  passed  into 
the  nose. 

When  this  has  been  done  and  no  relief  given,  ample  investi- 
gation of  the  patency  of  the  nasal  duct  should  follow,  and  the 
problem  of  trying  to  imitate  nature's  intention  by  the  forma- 
tion of  a  new  opening  into  the  nose  is  to  be  considered.  In 
view  of  the  necessity,  the  latter  is  more  frequently  accom- 
plished and  often  is  followed  by  a  satisfactory  result  for  the  time, 
but  the  ultimate  effect  is  not  to  the  benefit  of  the  growing 
infant. 

What,  then,  is  to  be  done  when  the  judgment  which  should 
come  from  experience  determines  an  operation  not  advisable  in 
the  individual  case?  Before  mutilating  the  child  it  may  be 
well  to  assist  nature  to  do  the  work  so  well  undertaken,  but  yet 
not  completed,  and  by  milder  measures  enable  the  child  to  en- 
joy that  comfort  which  with  harsher  methods  it  could  not. 

With  the  aid  of  cocaine  we  can  in  some  cases,  by  the  use  of 
fine  probes,  frequently  and  gently  passed  to  the  bottom  of  the 
sac,  stimulate  its  development,  and  finally  obtain  a  canal  of  suf- 
ficient calibre  to  enable  the  passage  of  the  secretions  from  the 
eye,  which  may  increase  in  size  with  the  facial  development  of 
the  child. 

The  treatment  consists  in  removing  the  discharge  which  ac- 
cumulates at  the  inner  corner  of  the  eye  and  the  use  of  a  mild 
eye  lotion,  as  that  of  borax  and  boracic  acid  (grs.  x.  aa  to  /5i.), 
which  lessens  the  irritation  arising  from  the  retention  of  the 
lachrymal  secretions,  and  tends  to  improve  the  septic  condition 
and  thus  prevent  the  extension  of  the  inflammation  to  the  con- 
junctiva of  the  lids  and  eyeball.  After  the  eye  has  been  thor- 
oughly cleansed,  some  mild  astringent  solution  may  be  either 
dropped  into  the  eye  or  used  in  a  lachrymal  syringe,  when  the^ 


LACHRYMAL  DISEASES— REMEDIES.  101 

lotion  may  be  thrown  directly  into  the  sac  and  forced  through 
the  nasal  duct  into  the  nose. 

The  internal  medication  consists  in  the  use  of  such  reme- 
dies as : 

Aconite. — Indicated  when  the  mucous  membrane  presents 
the  same  hypertrophied  condition  which  was  present  in  the 
conjunctival  affection  which  precedes  or  accompanies  it. 

Euphrasia. — Indicated  in  similar  conditions  to  aconite  and 
frequently  follows  the  latter  when  the  discharge  becomes  thick, 
yellow  and  acrid. 

Pulsatilla  and  Calc.  Carb. — When  there  is  a  profuse,  thick 
and  bland  discharge,  the  concomitants  deciding  the  choice. 

Argent  Nit. — Catarrh  of  the  lachrymal  sac,  when  the  dis- 
charge is  profuse  and  the  caruncle  and  semi-lunar  folds  appear 
red  and  inflamed. 

Petroleum. — This  remedy  has  a  marked  action  upon  the 
mucous  membrane  of  the  lachrymal  sac  when  the  obstruction 
is  due  to  thickening  of  the  mucous  folds.  The  temporary 
stricture  is  often  relieved  by  it  without  the  necessity  of  opera- 
tive interference. 

Calendula. — Particularly  useful  in  obstinate  cases,  when  the 
blennorrhoea  continues  after  the  duct  has  been  opened,  and 
the  stricture  tends  to  re-form,  and  should  be  applied  locally,  as 
well  as  given  internally. 

Stannum. — Relieves  some  cases  of  blennorrhoea  of  the  sac, 
where  there  is  a  profuse,  yellowish-white  discharge  with  sharp 
pain  or  itching  of  the  inner  canthus,  particularly  at  night. 

Arsen.  lod. — Proves  useful  in  curing  obstructions  of  the  duct 
dependent  upon  acute  inflammation  and  swelling  of  the  nasal 
mucous  membrane.  It  may  be  suitable  in  those  cases  of  blen- 
norrhoea of  the  duct  accompanied  by  a  dry  ulcerated  condition 
of  the  nostrils. 

Hepar  Sulph. — In  inflammatory  conditions  of  the  sac  with 
sensitiveness  to  touch,  and  free  discharge  of  pus  with  or  with- 
out an  opened  canaliculus. 

Mercurius. — The  discharge  is  thin,  acrid,  and  often  excor- 
iates the  lid-margins,  or  the  cheek  where  the  overflow  comes 
in  contact  with  it. 

Silicea. —  There  is  a  bland,  whitish  discharge  of  decomposed 
mucus  and  pus  from  the  distended  sac  after  the  canaliculus 
has  been  opened  and  probing  begun.  It  may  be  also  indicated 
in  the  recurrent  inflammatory  attacks  of  old  cases  of  blennor- 
rhoea of  the  sac. 

Many  other  remedies  have  been  recommended  and  have  un- 
doubtedly been  of  service  in  improving  the  condition,  as  arum 
tr.,  aurum  mur.,  belladonna,  calc.  carb.,  cuprum  alumina,  hy- 


102  THE  DISEASES  OF  CHILDREN. 

drastis,  fluor.  ac,  kali  iod.,  natrum  mur.,  nux  vomica,  sulphur 
and  zinc,  sulph. 

Strabismus  (squint  or  cross-eye)  is  a  deviation  of  one  of  the 
eyes  when  looking  at  an  object,  owing  to  the  inability  of  the 
child  or  individual  to  bring  the  eyes  to  bear  upon  the  object  so 
that  the  visual  axes  meet  at  the  point  of  the  object  looked  at. 
In  the  normal  state  of  the  eye  muscles,  when  any  object  is 
looked  at,  the  visual  axes  of  both  eyes  are  directed  to  the  same 
point  of  the  object.  When  squint  is  present,  both  eyes  are  not 
equally  turned,  one  eye  being  directed  toward  the  object,  while 
the  imaginary  line  of  the  visual  axis  of  the  other,  passes  to  one 
side  or  the  other  of  the  object,  and  the  squinting  eye  turns 
inward  (strabismus  convergens),  or  outward  (strabismus  diver- 
gens),  or  upward  (strabismus  deorsum  vergens),  or  downward 
{strabismus  sursum  vergens). 

The  six  muscles  of  each  eye  which  enable  the  eyes  to  assume 
their  varied  positions,  are,  when  normal,  so  evenly  balanced, 
that  all  motions  of  the  eye  in  their  associated  movements  are 
in  perfect  co-ordination,  and  the  visual  axes  meet  at  the  object 
to  which  the  eyes  are  directed.  When  from  any  cause,  one  or 
more  muscles  present  an  excess,  or  a  lack  of  innervation,  a  dis- 
turbance of  the  normal  equilibrium  occurs.  In  the  associated 
action  of  the  eyes  there  is  a  deviation  from  their  proper  direc- 
tion in  looking  at  an  object,  and  the  deviating  or  squinting  eye 
takes  the  direction  of  the  strongest  muscle. 

Strabismus  is  an  objective  symptom  arising  from  various 
causes.  If  it  occurs  in  acute  illness  it  is  a  grave  prognostic. 
It  may  occur  as  a  reflex  of  the  stomach  and  intestines,  from 
worms,  or  other  scources  of  local  irritation  or  inflammation; 
from  meningeal  and  cerebral  lesions,  which  may  cause  tonic 
spasm  and  paralysis  of  certain  of  the  eye  muscles. 

In  the  convulsions  of  infancy,  squint  is  often  a  symptom 
which  becomes  permanent,  or  afterwards  disappears.  When 
the  eye  becomes  crossed  in  the  course  of  tubercular  meningitis, 
it  is  a  symptom  of  approaching  death.  Whooping  cough, 
measles,  scarlet  fever,  diphtheria  and  other  diseases  of  child- 
hood are  fruitful  causes  of  strabismus,  owing  to  the  enfeeble- 
ment  of  one  or  more  of  the  eye  muscles  during  or  following 
the  disease,  and  a  consequent  disturbance  of  the  balance  of  the 
relative  powers  of  the  muscles.  An  eye  in  infancy  or  child- 
hood during  its  exclusion  from  light  and  the  associated  visual 
acts  of  its  fellow,  owing  to  the  bandaging  which  may  be  neces- 
sary for  its  restoration  to  health,  is  not  infrequently  found  to 
turn  inward  or  outward  when  recovery  from  the  inflammation 
or  ulceration  is  complete.     When  the  vision  has  been  partially 


STRA  BISM  US—  THE  A  TMEN  T.  103 

lost  as  a  result  of  such  inflammations,  the  squint  may  appear  at 
a  later  period.  Various  other  causes  are  assigned  by  the  par- 
ents for  its  production,  but  their  etiological  value  are  too  often 
impossible  for  the  ophthalmic  surgeon  to  determine.  Squint 
rarely  exists  at  birth  and  is  developed  usually  as  the  result  of 
the  close  approximation  of  the  infant's  near-point  and  its  effort 
to  observe  objects  attentively.  At  first  it  may  only  be  ob- 
served occasionally  (periodic  strabismus),  or  noticed  perhaps  in 
one  eye  and  again  in  the  other  (alternating  strabismus),  or  later 
becomes  a  permanent  squint  of  one  or  both  eyes. 

The  common  cause  of  this  deformity  is  that  which  arises 
from  the  imperfect  development  of  the  optical  apparatus,  the 
power  of  accommodation  or  other  defects  which  affect  the  recep- 
tion and  transmission  of  the  objects  looked  at.  There  is  still  a 
difference  of  opinion  as  to  the  origin  of  the  strabismus  and  the 
loss  of  vision  which  occurs  in  the  squinting  eye. 

That  there  is  either  an  early  innervation  of  the  muscles,  an 
ametropic  condition  of  the  refraction,  or  a  loss  of  central  vision 
in  many  cases,  all  agree.  The  question  as  to  the  cause  of  loss 
of  vision  in  the  squinting  eye,  whether  due  to  the  suppression 
of  the  image  (amblyopia  exanopsia),  or  defects  of  the  retinal 
function  still  remains  undetermined. 

Treatment. — When  strabismus  still  persists  after  the  acute 
disease  which  may  have  produced  it  has  passed,  and  the  devia- 
tion is  due  to  paralysis  of  the  opposing  muscle,  attention  should 
be  directed  to  the  improvement  of  innervation  of  the  paretic 
muscle  by  galvanism  and  such  remedies  as  may  be  indicated 
by  the  concomitant  symptoms. 

As  the  common  cause  of  non-paralytic  squint  is  either  a  nat- 
ural preponderance  of  the  internal  recti  muscles  over  the  ex- 
ternal or  a  hypermetropic  or  other  defective  conditions  of  the 
refraction  with  their  increased  demands  for  convergence,  we 
have  first  to  correct  the  ametropic  refraction  with  properly  ad- 
justed glasses.  This  is  usually  impracticable  under  four  years  of 
age,  as  while  it  is  possible  to  determine  gross  errors  of  refraction 
in  young  children  with  the  ophthalmoscope,  the  use  of  glasses 
thus  prescribed  are  usually  of  no  value  and  certainly  in  the  ma- 
jority of  cases  a  matter  of  great  anxiety  to  the  parent  or  attend- 
ant of  the  child.  Bandaging  the  non-squinting  eye  for  stated 
periods  each  day,  or  the  use  of  atropiato  paralyze  the  accommo- 
dation continually  or  daily  exercise  of  the  muscles  by  prisms 
afford  much  better  results  in  the  majority  of  cases  in  very 
young  children.  With  increased  age,  the  development  of  the 
nose-bridge  and  the  medial  sinuses,  by  increasing  the  pupillary 
distance  causes  a  disappearance  of  many  convergent  squints. 
The  development  of  the  eye,  and  its  muscles  accompanying 


104  THE  DISEASES  OF  CHILDREN. 

that  of  the  head  and  face  results  in  an  ability  to  co-ordinate  the 
muscles  properly.  In  all  cases  special  attention  should  be  given 
to  improve  the  general  nutrition  which  is  too  often  at  fault. 
When,  however,  by  the  use  of  such  remedies  as  gels.,  arg. 
nit.,  cicuta,  cina,  belladonna,  hyoscyamus,  jaborandi,  spigelia 
and  santonine,  which  may  be  indicated,  both  by  their  direct 
action  upon  the  muscles  at  fault  or  when  such  other  measures 
as  those  already  stated  have  been  of  no  avail,  it  is  necessary  to 
make  a  tenotomy  of  the  muscle  which  exhibits  the  greater  over- 
action.  When  the  operation  should  be  done,  and  its  extent^ 
can  only  be  determined  by  the  ophthalmic  surgeon,  when  he 
has  assured  himself  that  all  else  has  been  done  for  its  non-sur- 
gical cure.  In  the  event  of  an  operation,  in  young  children 
particularly,  it  is  well  to  do  too  little  rather  than  too  much,  as 
the  full  correction  or  over-correction  is  not  always  apparent 
until  some  months  have  passed.  The  operation  is  made  ordi- 
narily for  its  cosmetic  effect,  as  in  the  majority  of  cases  the 
vision  of  the  squinting  eye  is  not  recovered  as  a  result  of  the 
operation  and  should  not  be  expected,  nor  should  the  glasses 
which  have  been  used  to  correct  the  ametropia,  be  expected  to 
be  discontinued,  as  the  tenotomy  which  has  corrected  the  devi- 
ation has  not  removed  the  refractive  error  which  still  persists 
as  an  active  cause  and  tends  to  reproduce  the  squint.  For  the 
technique  of  the  operation  reference  should  be  made  to  special 
works  upon  the  eye. 

When  the  strabismus  is  due  to  paralysis,  operative  measures 
are  not  to  be  undertaken  until  all  possible  chances  of  recovery 
have  passed,  and  then  not  with  the  expectation  that  anything^ 
can  be  accomplished  except  to  lessen  the  cosmetic  defect. 

Heterophoria,  is  a  term  given  by  Dr.  S.  T.  Stevens,  of 
New  York,  to  a  disturbance  of  the  equilibrium  of  the  eye  mus- 
cles, and  is  a  condition  which,  while  formerly  considered  under 
the  term  muscular  insufficiency,  has,  owing  to  his  investigations, 
become  a  condition  of  greater  importance  as  regards  its  deter- 
mination and  the  effect  upon  the  use  of  the  eyes  and  those 
reflex  conditions  which  may  follow  certain  derangements  of 
the  eye  muscles.  In  general  explanation  it  may  be  said  if  the 
eye  muscles  are  of  normal  equilibrium,  orthophoria  is  present ; 
if  this  equilibrium  is  disturbed,  then  heterophoria  is  present ; 
the  visual  lines  in  the  former  being  parallel,  while  the  latter, 
owing  to  muscular  insufficiency,  tend,  as  in  strabismus,  to  de- 
viate. The  heterophorias  are  subdivided  into  esophoria,  when 
the  visual  lines  tend  inward  (insufficiency  of  the  external  recti); 
exophoria,  when  they  tend  outward  (insufficiency  of  internal 
recti);  and  hyperphoria,  when  that  of  either  eye  tends  upward. 


THE   USE  OF  GLASSES.  105 

The  determination  and  measure  of  these  muscular  deficien- 
cies is  accomplished  by  the  use  of  prisms,  which  are  succes- 
sively placed  before  the  eye  whose  muscles'  strength  is  under 
examination,  both  eyes  being  directed  upon  a  candle  or  other 
source  of  illumination  at  a  distance  of  twenty  feet,  the  thin 
edge  of  the  prism  being  placed  in  the  direction  of  the  muscle 
under  examination.  The  degree  of  the  strongest  prism  thus 
used,  which  still  enables  the  individual  to  maintain  single  vision, 
gives  the  strength  of  the  muscle  tested,  and  is  to  be  compared 
with  approximate  standard  for  that  muscle.  Various  modifi- 
cations of  this  simple  test  are  often  necessary  to  determine  the 
individual  loss  of  equilibrium  which  may  exist,  and  it  should 
be  borne  in  mind  that  all  such  values  are  only  relative. 

The  causes  of  the  heterophoria  are  those  arising  from  mal- 
nutrition, rapid  growth,  innervations  incident  to  approaching 
puberty,  eye  strain  dependent  upon  errors  of  refraction,  and 
depressions  of  the  muscular  and  nervous  systems  accompany- 
ing or  following  exhausting  diseases. 

The  presence  of  these  insuflficiencies  of  the  ocular  muscles 
are  undoubtedly  the  cause  of  much  discomfort  to  children  in 
the  use  of  their  eyes,  headache,  and  perhaps  more  neurotic 
symptoms,  as  chorea  and  epilepsy.  It  should  be  said,  however, 
that  they  are  more  frequently  the  reflex  of  disturbance  of  re- 
mote organs,  than  they  are  cause  of  the  many  affections  attrib- 
uted to  them. 

The  treatment  consists  primarily  in  the  correction  of  the  nu- 
trition ;  correction  of  the  optical  defects  by  the  use  of  glasses ; 
the  regulation  of  the  use  of  the  eyes ;  proper  exercise  and  good 
hygiene ;  the  methodic  exercise  of  the  eye  muscles  by  means 
of  prisms,  and  in  the  failure  of  these,  a  graduated  tenotomy  of 
the  stronger  muscle  may  be  made,  but  always  with  the  greatest 
of  care,  and  when  only  there  seems  no  chance  for  natural 
recovery  of  this  weakened  power  of  the  muscle  in  the  child. 

The  Use  of  Glasses. — Amatus  and  Friar  Bacon  discovered 
during  the  thirteenth  century,  that  a  bit  of  glass  with  a  convex 
surface,  when  placed  before  their  eyes,  enabled  them  again  to 
see  with  eyes  that  had  become  dimmed  by  the  changes  inci- 
dent to  their  advancing  age.  This  invention  and  its  practical 
application  has  been  of  inestimable  advantage  to  the  world  ; 
improving  sight  at  all  ages,  lessening  the  number  of  the  blind, 
lengthening  the  days  of  the  aged,  advancing  civilization  and 
making  the  world  brighter  and  better  for  all. 

The  question  is  often  asked,  Why  do  so  many  children  wear 
glasses  now-a-days?  The  frequency  with  which  one  now  meets 
children  of  all  ages  wearing  lenses  is  rather  startling  to  the 


306  THE  DISEASES  OF  CHILDREN. 

many  who  do  not  appreciate  the  possible  needs  which  require 
their  use  nor  know  of  the  good  which  is  accomplished  by  them. 

As  the  child  passes  from  infancy  to  childhood,  defects  and 
disturbances,  before  unnoticed,  now  become  fully  recognized  as 
the  child  attains  an  age  when  it  can  communicate  them.  Again, 
as  it  begins  also  to  exercise  the  visual  function  more  closely 
and  for  a  longer  time,  this  is  particularly  true  of  those  children 
who  are  placed  in  kindergartens,  where  the  character  of  some 
of  the  work  to  which  they  are  put  is  such  as  to  strain  the  eyes 
of  those  much  older  and  stronger.  While  the  work  itself  does 
not  cause  the  defects  of  vision  or  muscular  insuflficiencies 
which  we  frequently  find  to  be  present,  it  does  bring  out  these 
defects  at  an  earlier  age  than  under  other  circumstances.  When 
children  begin  to  use  their  eyes  intelligently  upon  the  objects 
around  them,  an  inquiry  should  be  made  into  the  power  and 
extent  of  the  visual  function.  It  is  an  error  for  the  parent  to 
consider  that  the  child  must  have,  by  reason  of  its  birth,  eyes 
of  the  same  formation,  visual  power  and  endurance  as  his  own. 
The  examination  of  many  thousands  of  children's  eyes  exhibits 
the  fact  that  the  proportion  of  normal  eyes  is  only  about  1 1 
per  cent. ;  the  balance  exhibiting  various  refractive  errors,  as 
hyperopia,  myopia  and  astigmatism  in  the  order  given.  The 
presence  of  these  defects  interferes  both  with  the  vision  and  also 
with  normal  and  comfortable  use  of  the  eyes.  In  the  effort  to 
see,  the  child  is  compelled  to  exercise  an  undue  amount  of 
force  in  trying  to  overcome  the  defect.  The  continued  effort 
thus  needed  results  in  a  rapid  exhaustion  of  that  reserve  energy 
which  is  needed  for  the  maintenance  of  the  normal  equilibrium 
of  the  general  nervous  system.  Complaint  is  made  of  the 
vision  and  the  eyes,  the  head  suffers,  various  reflex  nervous 
symptoms  are  excited  and  the  condition  presents  a  serious 
aspect. 

The  confinement  of  the  child  to  the  too  often  impure  air  of 
the  school  room,  the  forcing  process  common  to  our  school 
system  of  to-day,  the  method  of  education  by  means  of  the 
eye  in  which  learning  is  acquired  by  writing,  all  tend  to  weaken 
both  the  child's  physical  condition  and  the  eyes  as  well. 

With  the  acquirement  of  exact  knowledge  of  the  eye  condition, 
its  various  defects  and  needs,  the  ophthalmic  surgeon  finds  that 
the  correction  of  the  errors  of  refraction  by  properly  adjusted 
glasses  results  in  a  restoration  of  the  vision,  relief  of  the  eye 
strain,  improvement  of  the  disposition  of  the  child,  in  the  dis- 
appearance of  many  obscure  nervous  symptoms  which  were 
undoubtedly  reflex,  and  sometimes  the  cure  of  an  apparent 
idiocy  due  to  mental  deficiency. 

The  use  of  glasses  at  an  early  age  also  enables  the  vision  to 


GENERA  L  DISEA  SES—CA  USA  TI VE  RE  LA  TION.      ]  07 

be  retained  in  many  cases  which  otherwise  would  be  blind 
before  puberty ;  again  by  their  use  the  imperfectly  developed 
eye  may  be  stimulated  to  such  an  extent  as  to  acquire  during 
the  early  years  of  life  a  more  nearly  normal  condition.  In  all 
cases  where  glasses  may  be  indicated  the  greatest  care  should 
be  exercised  in  their  selection  and  adaptation  to  each  individual 
case,  as,  when  not  properly  prescribed,  they  are  as  capable  of 
injury  as  those  which  suit  the  condition  are  of  good. 

SYSTEMIC  AND   GENERAL   DISEASES   IN  THEIR   CAUSATIVE   RE- 
LATION  TO    EYE     DISEASES   IN   CHILDHOOD. 

Intestinal  Diseases,  when  of  an  exhausting  nature,  may  pre- 
sent such  eye  complications  as  ulceration  or  abscess  of  the 
cornea  which  threaten  to  destroy  the  vision  and  are  at  the 
same  time  usually  prognostic  of  approaching  death.  Intestinal 
irritation  due  to  parasites  or  other  causes  frequently  pro- 
duces marked  affections  of  the  eyes,  such  as  temporary  blind- 
ness, attacks  of  weak  vision,  photophobia,  unequal  dilatation 
of  the  pupils,  strabismus,  morbid  nictitation  or  nystagmus. 

Dentition. — During  the  eruption  of  the  teeth  the  eyes  ex- 
hibit a  tendency  to  exacerbation  of  any  existing  eye  inflamma- 
tion and  the  development  of  such  affections  as  blepharitis 
marginalis,  phlyctenular  inflammation  of  the  cornea  and  con- 
junctiva, mild  attacks  of  catarrhal  conjunctivitis  and  hyper- 
emia of  the  conjunctiva  with  lachrymation. 

Scrofula  exhibits  usually  such  superficial  affections  of  the 
€ye  as  inflammation  of  the  lid-margins,  phlyctenular  inflam- 
mations of  the  conjunctiva  and  cornea,  which  are  character- 
ized by  tediousness,  recurrence,  and  slowness  to  respond  to 
treatment. 

Syphilis  produces  a  varied  and  profound  effect  upon  the 
eyes  of  children  as  well  as  adults,  and  any  tissue  of  the  eye 
may  suffer  from  its  ravages.  Acquired  syphilis  as  a  cause  of  con- 
genital changes  in  the  eye  has  already  been  referred  to,  as  well 
as  that  form  of  parenchymatous  keratitis  which  appears  be- 
tween the  ages  of  two  and  fifteen  years  and  rarely  in  after  life. 
Inflammation  of  the  iris,  choroid  and  retina  during  the  first 
three  or  four  years  of  life  are  not  uncommon.  Owing  to  the 
delicacy  of  the  structures  involved,  the  inflammation  resulting 
from  the  dyscrasia,  together  with  the  persistent  character, 
which  marks  the  attack,  the  danger  to  the  sight  of  the  child 
becomes  very  great. 

Rubeola  is  a  prolific  cause  of  certain  eye  affections.  At  its 
inception  a  mild  catarrhal  conjunctivitis  with  a  more  or  less 
marked  photophobia  is  usually  observed.     This  condition  may 


108  THE  DISEASES  OF  CHILDREN. 

pass  rapidly  into  a  muco-purulent  conjunctivitis  in  some  cases, 
or  even  a  dangerous  purulent  ophthalmia  of  a  croupous  vari- 
ety may  follow  and  be  destructive  to  the  eyes.  The  greater 
number  of  eye  diseases  due  to  measles,  however,  appear  as 
sequelae  and  by  no  means  always  following  immediately  after 
the  attack  of  the  eruptive  fever.  It  would  seem,  from  the 
great  variety  of  eye  affections  which  are  traceable  to  rubeola, 
that  no  other  disease  of  childhood  presents  so  great  a  number 
of  eyes  of  impaired  vision  or  function.  Undoubtedly  the 
poisonous  effect  of  the  exanthem  in  perverting  the  nutrition 
of  children  already  predisposed  to  malnutrition  from  various 
causes,  accounts  for  the  development  of  various  diseases  of  the 
lids,  cornea  and  conjunctiva,  as  well  as  those  functional  affec- 
tions of  the  eye  muscles  and  retina  which  are  so  common  to 
the  oculist.  Affections  of  the  optic  nerve,  such  as  optic  neu- 
ritis, may  complicate  an  attack  of  measles  from  retrocession  of 
the  eruption  or  follow  after. 

Rotheln  rarely,  if  ever,  presents  any  eye  complication  beyond 
that  of  a  mild  conjunctivitis,  which  usually  disappears  with  the 
recovery  of  the  child  from  its  attack  of  false  measles. 

Scarlatina,  while  presenting  commonly  only  a  transient 
hyperemia  of  the  conjunctiva,  with  increased  lachrymation 
coincident  with  erythema  of  the  skin,  sometimes  is  complicated 
with  a  rapid  loss  of  vision  ;  in  one  case  coming  under  my  obser- 
vation the  blindness  existed  for  four  days,  and  was  evidently 
due  to  the  toxic  effect  of  the  disease  upon  the  blood  without 
nephritic  complication.  Purulent  and  diphtheritic  inflamma- 
tions of  the  conjunctiva  occur  only  in  those  desperate  and  usu- 
ally fatal  cases  of  complicated  scarlatina.  The  sequelae  of 
scarlet  fever,  with  the  exception  of  the  nephritic  and  diph- 
theritic complications,  exhibit  no  such  tendency  to  produce  eye 
disturbances  as  does  measles.  When  the  eruption  is  repressed, 
cases  of  loss  of  vision  have  been  reported. 

Roseola,  varicella  or  vaccina  produce  no  eye  symptoms  of 
direct  value. 

Variola  may  destroy  vision  from  ulceration  of  the  cornea  ;  in 
rare  cases,  from  the  formation  of  a  pustule  upon  the  cornea  or 
upon  its  margins. 

Diphtheria  rarely  affects  the  eye  in  childhood,  except  by  di- 
rect inoculation,  or  from  extension  from  the  nose,  and  when  it 
occurs  destruction  of  both  sight  and  eye  follows.  As  the 
child  recovers  from  the  systemic  disease,  it  is  not  uncom- 
mon to  find  that  the  power  of  accommodation  for  near  objects 
has  been  lost.  While  the  prognosis  is  usually  good  in  these 
cases,  a  permanent  weakness  of  the  ciliary  muscle  undoubtedly 
remains  in  many  cases. 


GENERAL  DISEASES— CA  USA  TIVE  RELA  TION.      109 

Pertussis  in  its  convulsive  stage  may  cause  sudden  blindness 
from  hemorrhage  within  the  eye,  due  to  rupture  of  a  blood- 
vessel of  the  choroid  during  the  paroxysm,  or  in  other  cases 
from  an  ischemia  of  the  retina.  Spots  of  effused  blood  in  the 
conjunctiva  from  rupture  of  the  capillaries  are  a  very  frequent 
accompaniment  of  cough  paroxysms. 

Phlyctenular  inflammations  of  the  conjunctiva  and  ulcers  of 
the  cornea  are  not  infrequent  sequelae  of  this  disease. 

Parotitis  rarely  exhibits  any  eye  complication,  although 
cases  have  occurred  where  there  has  been  a  disturbance  of  the 
retina  with  temporary  failure  of  the  vision  and  others  present- 
ing a  passing  effusion  in  the  orbit  with  paresis  of  the  oculo- 
motor nerve. 

Cerebrospinal  Fever  may  be  complicated  with  ulceration  of 
the  cornea,  hyperemia  of  the  optic  disc  and  retina,  or  even  an 
acute  choroiditis,  with  exudation  of  lymph  in  the  vitreous  and 
blindness  result. 

Typhoid  Fever  seldom  occasions  any  disturbance  of  the 
eyes  except,  in  low  cases,  when  an  ulceration  of  the  cornea 
and  impaired  vision  are  due  to  exhaustion.  Optic  nerve  lesions 
appear  as  a  result  of  meningeal  complications. 

Intermittent  Fevers  in  children  show  a  proneness  to  eye  af- 
fections, both  during  the  course  of  the  fever  and  also  later. 
Iritis,  phlyctenules,  corneal  ulcers,  strabismus  and  heteropho- 
rias,  with  all  their  dangers  and  discomforts,  may  attend  or  follow 
an  attack  of  malaria. 

Rheumatism  rarely  causes  any  disease  of  the  eye  in  children 
except  in  extremely  rare  cases,  when  an  iritis  or  a  mild  scleritis 
may  occur. 

Diseases  of  the  Heart,  even  in  children,  produce  certain 
changes  in  the  eye  and  disturbance  of  the  visual  function,  the 
latter  coincident  with  valvular  diseases. 

Ex-ophthalmic  Goitre,  however,  is  the  most  common  eye  dis- 
ease arising  from  heart  complication.  It  appears  in  childhood 
only  at  the  approach  to  puberty  or  soon  after  the  menstrual 
function  has  been  established.  With  the  enlargement  of  the 
thyroid  and  disturbed  action  of  the  heart,  there  is  a  marked 
prominence  of  the  eyes  with  a  partial  retraction  of  the  upper 
eyelids  which  occasions  a  peculiar  stare  characteristic  of  the 
disease.  When  occurring  in  children  it  is  much  more  readily 
cured  when  early  recognized  and  treated,  than  in  adults. 

Hydrocephalus  causes  impairment  of  the  vision  either  from 
pressure  exerted  directly  upon  the  optic  tracts,  or  from  the  dis- 
turbance of  the  functional  activity  of  the  visual  centers  by  the 
distention  of  the  brain  cortex.  The  position  of  the  eyes,  as 
they  are  pushed  downward  by  the  pressure  upon  the  roof  of 


110  THE  DISEASES  OF  CHILDREN. 

the  orbits,  gives  to  the  hydrocephalic  child  a  fixed  stare  which 
is  unique.  In  the  early  stages  of  the  disease  strabismus  or 
nystagmus  may  be  observed. 

Diseases  of  the  Central  Nervous  System,  particularly  those 
of  gross  character,  such  as  tumors  of  the  brain,  rarely  find 
expression  in  the  eyes  of  children  unless  due  to  inherited 
syphilis,  when,  as  in  the  adult,  optic  neuritis  may  occur  before 
death. 

Meningitis,  however,  presents  not  only  the  paralysis  of  the 
ocular  muscles,  but  when  the  inflammation  involves  the  base 
of  the  brain,  optic  neuritis  and  consequent  atrophy  are  not 
uncommon. 

Diseases  of  the  Sexual  System  afford  many  cases  of  dis- 
turbances of  the  eye  relation  prior  to  and  at  the  time  of  pu- 
berty. It  is  a  noticeable  fact  that  a  more  marked  effect  is 
produced  upon  the  eyes  of  girls  at  this  period  than  those  of 
boys.  The  rapid  development  of  the  body  which  occurs  at  the 
time  of  puberty  is  often  preceded  by  a  variety  of  eye  symptoms 
which  are  often  alarming,  in  that  there  is  frequently  a  marked 
affection  of  the  vision,  a  disturbance  of  the  equilibrium  of  the 
eye  muscles  from  loss  of  physical  tone  or  occasioned  by  errors 
of  refraction  which  before  have  passed  unnoticed.  The  eye 
affections  thus  caused  become  not  only  causes  of  discomfort  to 
the  child,  but  produce  reflex  effects  of  both  the  head  and  the 
general  nervous  system  as  well.  In  cases  when  the  headaches, 
chorea  and  other  now  remote  nervous  symptoms  do  not  disap- 
pear when  such  local  causes  of  irritation  as  congested  ovaries, 
vaginal  inflammation,  contracted  or  adherent  prepuce,  or  the 
habit  of  masturbation  have  been  removed,  the  eyes  should  be 
well  examined  and  all  refractive  errors  and  muscular  defects 
corrected  as  far  as  possible,  and  often  with  remarkable  improve- 
ment in  the  child's  condition. 

The  effort  of  nature  to  establish  the  menstrual  function  in 
the  child  who  has  perhaps  reached  that  period  of  its  life  when 
it  should  pass  from  childhood  to  girlhood,  is  not  infrequently 
attended  by  various  disorders  of  the  eye  which  may  precede 
the  appearance  of  the  menses,  accompany  them,  or  remain 
until  the  function  becomes  regular.  Morbid  winking,  chorea  of 
the  eyelids  and  face,  spasm  of  the  lids,  asthenopia,  heterophoria, 
hysterical  loss  of  vision,  neuralgia  of  the  eye,  intra-ocular  hem- 
orrhages, choriditis,  neuro-retinitis  and  optic  neuritis  may  all 
arise  during  this  too  often  trying  period  of  the  child's  existence. 
In  the  male  child  abnormal  nictitation,  conjunctival  hyperemias, 
headaches  and  chorea  at  puberty  are  more  frequently  observed, 
while  the  deeper  eye  affections  are  uncommon. 

Injuries  of  the  Eye  in  Children — Traumatism   of  the  eye 


GENERAL  DISEASES— CA  USA  TIVE  RELA  TION.      \\\ 

of  the  child  has,  as  in  adults,  the  danger  to  sight  or  life  in 
proportion  to  its  extent  and  the  location  of  the  injury.  Upon 
the  care  given  immediately  after  the  accident  too  often 
depends  the  recovery  or  loss  of  sight.  It  is  impossible  to  pre- 
sent any  single  rule  for  the  proper  treatment  of  all  the  wounds 
and  injuries  of  the  eye  which,  small  as  the  organ  is,  when  the 
accidents  to  which  it  may  be  subjected,  are  so  numerous,  so 
frequent,  and  so  dangerous  to  the  delicate  organ  of  sight.  No 
matter  how  long  or  broad  the  experience  of  the  ophthalmic 
surgeon  may  be,  each  case  of  injury  to  the  eye  presented  to 
him  may  have  some  variation  in  cause,  location  of  lesion  or  effect 
upon  the  sight,  which  will  require  the  aid  of  all  his  experience 
and  skill  to  avoid  destruction  of  sight  or  eyeball,  and  yet  be 
compelled  to  witness  the  inability  of  his  efforts. 

In  young  children  the  retention  of  foreign  bodies  upon  the 
eyeball  or  beneath  the  lids  is  much  more  rare  than  in  adults, 
owing  to  the  lax  application  of  the  lids  to  the  surface  of  the 
ball,  and  also  to  the  more  active  condition  of  the  lachrymal 
gland,  which  at  this  stage  of  life  responds  so  readily  with  its 
shower  of  tears  upon  irritation  of  the  co'njunctiva.  When 
foreign  bodies  remain  upon  the  eyeball  or  beneath  the  lid, 
there  is  apparently  less  pain  referred  to  the  eye  than  in  adults, 
but  a  watery,  congestive  appearance  of  the  eye  or  an  inflamma- 
tion of  the  conjunctiva  is  presented,  and  the  first  duty  is  to  look 
for  the  cause  of  the  irritation  or  inflammation  which  may  be 
discovered  in  an  imbedded  bit  of  foreign  substance  in  the  cor- 
nea, conjunctiva  of  the  eyeball  or  lids,  the  child  being  less 
likely  to  complain  of  the  cause  of  the  trouble  than  the  adult. 
A  drop  or  two  of  a  two  per.  cent,  solution  of  cocaine  renders 
the  eye  sufficiently  anesthetic  to  enable  one  to  examine  it 
comfortably  to  the  patient  and  thoroughly  by  the  attendant,  so 
as  when  its  location  has  been  discovered  to  remove  it  without 
pain.  When  not  found  upon  the  surface  of  the  globe,  the 
upper  lid  should  be  everted,  when  its  location  will  be  found 
near  the  center  of  the  free  margin  or  at  the  angles  of  the  tar- 
sus. Its  removal  and  the  application  of  a  cold  compress  or  the 
instillation  of  a  mild  collyrium  is  usually  sufficient  to  cause  a 
return  of  the  eye  to  its  normal  condition  in  a  few  hours,  unless 
the  irritation  and  inflammation  have  been  excessive. 

The  dangerous  injuries  of  the  eye  from  which  the  child  is 
likely  to  sufifer  are  those  of  burns  and  scalds  from  hot  water, 
lime  and  mortar  and  hot  pokers,  punctured  wounds  arising 
from  forks,  scissors,  pointed  sticks  or  knives.  Not  infrequently 
the  pet  dog,  cat  or  monkey  have  in  my  experience  produced  by 
accident  or  intent  a  laceration  of  the  lids  or  eyeball.  Contusion 
of  the  lids  or  ball  from  blows  or  blunt  bodies,  such  as  sticks. 


112  THE  DISEASES  OF  CHILDREN. 

balls,  pebbles,  etc.,  may  cause  hemorrhages  within  the  eye,  or 
concussion  of  the  eye  sufficient  to  destroy  the  function  of 
sight  is  not  uncommon  among  older  children.  In  all  cases  the 
greater  danger  lies  in  the  effort  on  the  part  of  the  unskilled 
attendant  to  do  too  much.  The  fact  that  the  child  makes  little 
complaint  after  injury  to  the  eye  is  too  often  misleading,  as 
deep  injuries  to  the  eyeball,  both  in  children  and  adults,  produce 
an  anesthetic  condition  which  is  apt  to  prevent  an  early  and  a 
proper  recognition  of  their  extent  or  the  danger  incident  to 
them. 

When  foreign  bodies  or  masses  of  dirt  or  other  extraneous 
substances  have  found  their  way  upon  the  ball  or  beneath  the 
lids,  the  first  thing  to  do  is  to  remove  them  with  a  suitable  in- 
strument, or  by  washing  or  gently  syringing  the  eye  with  warm 
water  after  rendering  the  eye  anesthetic  by  cocaine ;  then  as- 
certain the  extent  of  the  injury  and  its  danger  to  eyeball  and 
sight,  and  apply  cold  compresses  and  such  antiseptic  coUyrium 
as  may  be  indicated.  In  cases  where  penetrating  wounds  of 
the  eyeball  have  occurred,  while  they  may  seem  very  slight  at 
first,  their  ultimate  results  may  be  very  grave,  and  the  medical 
attendant  can  rarely,  if  ever,  err  by  prescribing  a  proper  solu- 
tion of  atropia,  according  to  the  age  of  the  child,  to  dilate  the 
pupil,  and  apply  cold  compresses  of  ice  to  the  eye.  Efforts  to 
determine  the  extent  of  the  injury  by  too  much  examination 
by  unskillful  hands  result  in  the  destruction  of  eyes  which 
might  be  saved. 

In  all  extensive  injuries  of  the  eyeball,  such  as  great  lacera- 
tions or  where  foreign  bodies  have  been  projected  within  the 
eyeball,  the  danger  of  sympathetic  inflammation,  which  may 
destroy  the  sight  of  the  remaining  eye,  should  always  be  borne 
in  mind.  The  necessity  for  the  removal  of  the  injured  eye  to 
prevent  total  blindness  is  often  indicated ;  but  in  children, 
where,  in  the  absence  of  a  foreign  body  within  the  eye,  or  the 
laceration  is  not  too  great,  it  becomes  the  duty  of  the  ophthal- 
mic surgeon  to  consider  the  effect  which  the  immediate  re- 
moval of  the  eyeball  will  have  upon  the  development  of  the 
orbit  and  the  side  of  the  face  of  the  injured  eye.  In  all  cases, 
should  indications  of  a  sympathetic  irritation  or  inflammation 
supervene  in  the  other,  after  injury  of  one  eye,  no  time  should 
be  lost,  when  by  the  removal  of  the  injured  eye  it  may  be 
possible  to  save  the  sight  of  its  fellow. 

Glioma  of  the  Retina  and  Optic  Nerve,  or  Fungus  Hcmatodes, 
is  usually  the  only  malignant  tumor  of  the  eyes  of  children 
which  we  may  be  called  upon  to  consider.  It  is  almost  exclu- 
sively a  cancer  of  childhood,  occurring  usually  between  the 
ages  of  one  and  twelve  years ;  it  may,  however,  appear  as  early 


GENDER  A  L  DISEA  SES—  CA  USA  TI VE  REL  A  TION.      113 

as  the  second  month  after  birth.  It  is  probably  hereditary 
and  dependent  upon  a  cancerous  dyscrasia. 

The  earliest  symptom  is  a  whitish-yellow,  or  bluish-white  ap- 
pearance of  the  pupil,  which  on  examination  is  found  to  exist 
behind  the  lens,  and  the  eye  is  devoid  of  vision.  No  pain  or 
redness  is  present,  and  often  the  case  is  not  brought  for  treat- 
ment until  the  eye  becomes  enlarged,  or  pain  and  congestion 
of  the  sclera  occur.  As  the  tumor  grows  it  advances  into  the 
interior  of  the  eyeball,  producing  atrophy  and  detachment  of 
the  retina  as  it  proceeds.  With  the  ophthalmoscope  it  appears 
like  a  detachment  of  the  retina  or  inflammatory  changes  in  the 
vitreous,  which  closely  simulate  it,  and  from  which  it  must  be 
distinguished  by  the  absence  of  iritic  adhesion,  and  from  the  his- 
tory of  the  inflammation  preceding  the  white  or  yellowish  ap- 
pearance of  the  pupil.  The  appearance  of  the  vessels  upon  the 
surface  of  the  bulging  mass,  which  do  not  correspond  with  those 
of  the  retina,  will  enable  us  to  designate  it  from  other  affec- 
tions. As  the  tumor  increases  in  size  the  intra-ocular  tension 
increases,  and  the  pupil  becomes  dilated  and  the  child  com- 
plains of  pain  from  the  glaucomatous  condition  which  occurs ; 
other  portions  of  the  tissues  of  the  globe  become  involved 
with  the  increase  of  the  tumor,  and  the  lens  loses  its  trans- 
parency, the  cornea  becomes  opaque,  and  all  semblance  of 
the  eyeball  is  lost  in  the  protruding  mass  which  extrudes 
between  the  lids  and  appears  as  a  fleshy  body,  secreting  a 
sanious  discharge  and  subject  to  frequent  hemorrhages  in  the 
advanced  stage  of  the  disease,  when  it  is  called  fungus  hema- 
todes  of  the  eye. 

When  the  disease  is  recognized  in  the  early  stages,  while 
confined  to  the  retina,  the  removal  of  the  eyeball  with  a  por- 
tion of  the  optic  nerve,  which  on  examination  shows  no  sign 
of  implication,  is  usually  favorable.  The  case,  however,  is  even 
then  not  safe  until  several  months  or  a  year  have  passed  with- 
out indications  of  the  return  of  the  growth.  In  the  majority 
of  cases  the  removal  of  the  eye  is  not  acceded  to,  or  the  disease 
has  progressed  along  the  optic  nerve  so  that  the  brain  is  often- 
times affected,  or  the  contents  of  the  orbit  have  become  infil- 
trated with  cancerous  cells,  so  that  death  follows  at  an  early 
date,  from  intra-cranial  tumor  or  exhaustion  due  to  the  can- 
cerous cachexia. 

Immediate  removal  of  the  ball,  with  as  great  a  portion  of  the 
optic  nerve  as  possible,  is  imperative  when  the  tumor  is  con- 
fined to  the  interior  of  the  eye.  When  it  has  extended  beyond 
the  confines  of  the  globe,  the  question  of  operative  interference 
is  a  grave  one,  as  often  the  complete  extirpation  of  the  con- 
tents of  the  orbit  affords  only  temporary  relief,  the  sarcoma- 
D.  C— 8 


lU  THE  DISEASES  OF  CHILDREN. 

tous  mass,  under  these  circumstances,  seeming  to  acquire  fresh 
energy  from  the  operative  measures. 

In  extremely  rare  cases  the  growth  is  reported  to  have  been 
checked  and  the  eyeball  becomes  atrophied,  but  this  is  so 
unusual,  and  the  general  tendency  of  the  disease  so  fatal,  that 
time  should  not  be  lost  in  awaiting  probable  absorption. 
After  the  removal  of  the  growth,  it  is  my  practice  to  place 
these  patients  upon  carbolic  acid  ist  dec.  in  water,  a  dose  three 
times  a  day  for  several  months,  and  good  results  have  occurred 
from  its  use. 


CHAPTER  II. 

DISEASES  OF  THE  EAR. 

The  infant  ear  at  birth  rarely  receives  as  much  attention  as 
the  eye,  unless  an  absence  of  the  auricle  excites  the  notice  of 
the  attendant  or  some  other  deformity  is  apparent.  As  the 
ear  is  not  susceptible  to  those  destructive  inflammations  due  to 
inoculation  from  the  abnormal  vaginal  secretions  of  the  mother 
soon  after  birth  as  the  eye,  it  naturally  requires  less  careful 
examination. 

Congenital  Malformations  are,  however,  too  often  pres- 
ent  as  a  result  of  a  partial  or  complete  arrest  of  development 
in  utero,  and  the  auricles  may  be  so  rudimentary  as  to  be  said  to 
be  absent  on  one  or  both  sides.  When  the  auricle  is  rudiment- 
ary, the  external  auditory  canal  may  also  be  absent  or  be  closed 
by  a  fold  of  skin,  which  prevents  the  passage  of  sound  vibrations 
to  the  middle  ear.  When  the  auricle  is  congenitally  non-de- 
veloped, there  is  usually  some  rudimentary  evidence  of  nature's 
effort  to  complete  the  work,  as  is  shown  by  the  presence  of  no- 
dules of  skin  and  cartilage  in  the  vicinity  of  the  site  of  what 
should  have  been  an  auricle.  With  the  non-development  of 
the  auricle,  there  is  usually  associated  a  similar  defect  in  the 
external  auditory  meatus  and  also  one  of  the  middle  and  in- 
ternal ear,  so  that  surgical  interference,  which  might  seem  indi- 
cated for  the  purpose  of  opening  the  canal,  is  rarely  of  any 
value  for  the  relief  of  the  deafness  which  accompanies  the 
defect. 

Various  deformities  of  the  external  ear  may  be  present  as 
congenital  defects,  such  as  a  malformed  auricle,  where  a  high 
degree  of  hypertrophy  is  exhibited,  or  arrest  of  development 
and  an  asymmetry  of  the  two  ears  confront  us ;  clefts  and  fis- 
sures of  the  auricle,  when  present,  or  when  the  angle  of  its 
insertion  may  give  an  abnormal  expression  to  those  appen- 
dages, as  where  the  auricles  are  too  closely  applied  to  the 
head  or  are  set  at  a  too  advanced  angle  with  the  plane  of  the 
head.  Such  anomalies,  while  not  necessarily  interfering  with 
the  child's  hearing,  oftentimes  cause  in  the  child,  as  it  advances 
in  years,  a  marked  disfigurement,  and  our  efforts  toward  an  im- 
provement of  the  condition  are  rarely  followed  by  any  gain  in 

(115) 


116  THE  DISEASES  OF  CHILDREN. 

esthetic  effect.  A  congenital  fistula,  situated  in  the  ascending 
portion  of  the  helix  of  the  auricle,  the  opening  leading  into  a 
blind  canal,  with  a  thick,  creamy  secretion,  has  been  recorded, 
as  well  as  certain  fistulas  of  the  canal  communicating  with  the 
middle  ear.  The  external  auditory  canal  is  more  often  the  seat 
of  congenital  abnormalities  than  that  of  the  auricle,  and  may  ex- 
hibit throughout  the  whole  extent  conditions  of  contraction  or 
closure  due  to  cuticular  or  osseous  hypertrophy.  With  a  full  de- 
velopment of  the  auricle  and  a  partial  or  complete  closure  of 
the  auditory  canal,  we  not  infrequently  find,  after  perforation 
of  the  skin  or  bone  which  seemed  to  intervene  between  the  ex- 
ternal and  middle  ears,  that  the  canal  ends  in  a  cul-de-sac  and 
that  the  middle  ear  is  without  proper  development ;  hence  our 
surgical  efforts  for  the  correction  of  such  conditions  are  usually 
without  good  result. 

Congenital  malformations  of  the  drum-membrane,  the  middle 
ear  or  the  internal  ear  are  rarely  noticed  in  infancy,  although 
they  may  be  present.  When  the  child  has  arrived  at  a  period 
of  its  existence  when  its  mental  development  seems  to  be  at 
fault,  its  speech  absent  or  its  hearing  in  doubt,  we  often  find 
on  examination  that  there  are  physical  defects  of  the  auditory 
apparatus  which  are  sufficient  to  explain  these  deficiencies. 
They  are  usually  not  remediable,  so  that  the  child,  when  both 
ears  are  affected,  is  a  deaf-mute  and  should  be  afforded  that 
education  applicable  to  the  deaf  and  dumb  which  is  necessary 
to  make  such  children  bread-winners  and  intelligent  members 
of  the  community  in  which  they  may  reside. 

At  birth  the  external  auditory  canal  is  filled  with  a  plug  of 
detritus,  in  which  epithelial  cells  from  the  epidermis  lining  it 
are  found  mixed  with  the  caseous  material  which  covers  and 
protects  the  fetus  during  its  intra-uterine  life ;  the  accumulation 
soon  after  birth  dries  up  and  falls  out,  or  later,  when  attention 
may  be  called  to  the  infant's  ears  and  the  plug  found  to  be  still 
there,  its  removal  is  to  be  accompHshed  by  the  use  of  the  aural 
syringe. 

The  middle  ear  cavity  may  also  at  birth  have  retained  the 
debris  incident  to  its  development.  This  accumulation  should 
pass  out  through  the  eustachian  tube  into  the  throat,  leaving 
the  middle  ear  in  condition  for  the  conduction  of  sound;  it 
probably  does  not  do  so  as  frequently  as  is  supposed.  When 
this  condition,  is  present,  its  effect  is  to  cause  deafness  and  re- 
tard the  hearing  perception  of  the  infant,  and  acting  as  an  irri- 
tant sets  up  a  suppurative  inflammation  which  liquefies  the  mass, 
so  that  if  the  eustachian  tube  is  pervious  it  passes  into  the 
throat,  or  when  the  latter  does  not  open  under  the  pressure  of 
the  accumulation,  the  drum-head  ruptures  and  those  early  sup- 


CONGENITAL  MALFORMATIONS.  117 

purations  of  the  middle  ear  which  occur  during  the  first  month 
or  two  of  infantile  life  are  explained. 

The  ear.  of  the  new-born  does  not  present  that  completeness 
of  development  which  is  found  in  the  eye  at  the  same  period. 
The  orbits  of  the  eyes  exhibit  in  the  infant  a  much  greater  de- 
velopment at  birth  than  does  the  temporal  bone  in  which  the 
auditory  organ  has  its  location  and  upon  which  its  develop- 
ment depends.  While  the  eyeballs  and  their  appendages  at 
birth,  when  normal,  closely  approximate  the  size  and  shape  of 
those  of  adult  life,  the  ears  present  much  less  advancement  in 
the  scale  of  development. 

The  temporal  bone  at  the  time  of  birth  differs  materially 
from  that  of  the  adult,  and  as  the  essential  portions  of  the  hear- 
ing apparatus  are  inclosed  in  its  structure,  the  development  of 
the  ear  is  in  close  relation  to  its  ossification,  which  proceeds 
slowly  and  yet  always  within  keeping  of  that  development  of 
the  skull  which  accompanies  the  normal  physical  and  mental 
development  of  the  child. 

In  the  early  stages  of  infancy  one  looks  in  vain  for  an  audi- 
tory canal  of  full  length  or  a  drum-head  in  the  position  of  that  of 
adult  life.  The  external  auditory  canal  has  at  this  time  of  in- 
fantile life  only  its  cartilaginous  portion,  is  short  and  the  osseous 
portion  undeveloped  ;  the  drum-membrane,  instead  of  being  vis- 
ible as  in  the  adult  at  an  acute  angle  with  the  lower  wall  of  the 
canal,  is  now  found  almost  horizontal  with  the  upper  wall. 

The  mastoid  process,  which  in  the  adult  temporal  bone  pre- 
sents a  flattened  conical  mass  with  apex  downward,  is  only  rudi- 
mentary in  the  infant,  and  only  becomes  prominent  in  a  physi- 
ological or  pathological  sense  with  the  progressive  development 
of  the  temporal  bone  and  that  of  the  child. 

The  examination  of  the  drum-membrane  in  early  infancy,  to 
determine  the  value  of  its  presenting  condition  in  connection 
with  other  symptoms  or  diseases  of  the  child,  is  accordingly  ac- 
complished only  with  effort,  and  variations  in  its  appearance 
when  seen  are  only  of  diagnostic  and  prognostic  value  after  many 
accurate  observations  have  been  made  of  other  ears  by  the  in- 
dividual examiner.  As  the  infant  becomes  more  developed,  its 
aural  affections  increase  in  frequency  and  extent  and  the  diag- 
nostic value  of  the  examination  of  its  ears  of  greater  impor- 
tance, not  only  in  determining  the  local  affection,  but  also  elim- 
inating the  ear  as  a  possible  cause  or  complication,  as  well  as 
presenting  often  a  prognostic  indication  as  well  as  an  aid  to 
rational  treatment. 

The  examination  of  the  ears  should  always  be  conducted 
under  such  circumstances  as  enable  one  to  see  the  condition  of 
the  meatus  and  drum-head  ;  the  instruments  necessary  are  a 


118  THE  DISEASES  OF  CHILDREN. 

speculum  to  dilate  and  straighten  the  canal,  and  a  mirror  re- 
flecting sufficient  light  to  illuminate  the  meatus  and  drum- 
membrane.  The  view  thus  obtained,  together  with  a  knowledge 
of  the  value  of  the  variations  from  the  normal  appearance  of 
these  parts  when  presented,  aid  us  to  give  a  greater  certainty 
to  our  diagnosis  and  prognosis  of  diseases  of  childhood  as  well 
as  those  of  adult  life.  Obstruction  to  view  of  the  canal  and 
deeper  parts  is  often  due  to  an  abnormal  lessening  of  its  cali- 
ber or  from  a  superabundant  secretion  of  cerumen,  so  that  it  is 
necessary  to  remove  the  accumulation  with  the  syringe  before 
the  examination  can  be  completed.  If  the  auricle,  which  was 
designed  for  the  collection  of  the  sound  vibrations,  the  meatus 
for  sound  conduction,  the  drum-head  to  receive,  the  small 
bones  of  the  middle  ear  to  conduct  still  further,  and  the  inter- 
nal ear  and  auditory  nerve,  all  possess  a  normal  receptive,  con- 
ductive and  transmissive  power,  then  the  consciousness  and 
determinative  value  of  the  impressions  received  and  transmitted 
depend  upon  the  functional  power  of  the  sound-areas  in  the 
cortex. 

Hearing  in  Infancy. — The  human  offspring  differs  in  its 
higher  grade  of  development  from  the  other  mammalia  as 
regards  the  power  of  audition  immediately  after  birth.  The 
perception  of  sound  in  the  young  of  all  the  higher  forms  of 
life  is  so  dulled  during  the  period  immediately  following  birth 
that  it  becomes  a  difficult  matter  to  separate  the  possible  value 
of  the  hearing  sense  from  that  of  cutaneous  impression.  The 
function  of  perfect  hearing  in  mankind  being  dependent  upon 
a  complete  developmental  expression  of  the  collective,  conduc- 
tive, transmissive  and  perceptive  apparatus  of  the  organ  of 
hearing,  it  should  not  be  expected  that  its  perfection  is  attained 
when  the  anatomical  and  histological  portion  in  infancy  are 
found  so  imperfect. 

In  a  series  of  experimental  observations  which  I  have  con- 
ducted at  various  times  upon  infants,  in  the  effort  to  determine 
the  power  of  their  auditory  function  soon  after  birth,  I  have 
found  it  difficult,  as  it  is  almost  impossible  to  have  the  sur- 
roundings in  keeping^  with  scientific  experiments,  so  that  re- 
peated observations  may  be  necessary  to  enable  one  to  arrive 
at  a  conclusion. 

When  an  examination  of  the  ears,  after  the  removal  of  the 
fetal  accumulation  which  fills  the  canal,  exhibits  the  normal  ap- 
pearance of  the  infantile  ear,  the  projection  of  sounds  toward 
the  ear,  even  when  loud,  discordant  or  musical,  seem  to  disturb 
the  ten-day-old  infant  less  than  vibrations  of  the  same  strength 
transmitted  through  the  floor,  its  crib  or  cradle.     At  this  age 


HEARING  IN  INFANCT.  119 

the  cutaneous  sense  appears  certainly  more  acute  than  its  audi- 
tory sense. 

While  the  general  theory  of  sound-sensation  is  still  in  doubt, 
there  are  some  theories,  such  as  those  which  pertain  to  the  re- 
ception and  transmission  of  sound  impressions  as  advanced  by 
Helmholtz,  which  remain  as  yet  undisputed.  The  mode  of 
reception  and  transmission  in  the  auditory  nervous  apparatus, 
however,  remain  for  investigation  and  speculative  thought. 

It  is  still  a  question  whether  the  optical  memory-pictures  of 
infantile  life  have  a  greater  retentive  value  than  those  memo- 
ries produced  by  the  sound  impressions.  Owing  to  the  greater 
development  of  the  eye  as  compared  with  the  ear  at  birth,  it  is 
probable  that  the  visual  impressions  at  this  period  of  life  are 
more  durable  than  those  of  sound. 

The  auditory  center,  which  is  situated  in  the  temporo-sphe- 
noidal  portion  of  each  side  of  the  brain,  has  the  inherent  power, 
when  properly  developed,  of  analyzing  the  impression  of  those 
complex  tones  transmitted  to  it,  as  well  as  determining  the  au- 
ditory value  of  all  simple  sounds  and  noises  which  excite  it.  It 
also  has  the  power  to  distinguish  for  the  individual  certain 
musical  tones,  when  a  proper  impression  has  been  made  upon 
the  organ  of  corti,  and  transmitted  to  the  auditory  sphere  of  the 
brain,  which  results  in  a  conscious  appreciation  of  their  rhyth- 
mic blending  and  the  interpretation  of  their  musical  significance. 

In  the  infant,  after  the  first  few  weeks  of  world  life,  as  it  be- 
gins its  perceptive  auditory  period,  the  lower  and  deeper  tones 
are  probably  alone  perceived,  hence  the  mother's  lullaby  is  of 
a  low,  if  not  always  a  sweet  or  musical  tone.  As  the  infant  ad- 
vances toward  childhood,  the  voice  tone  of  the  mother  or  at- 
tendant becomes  higher  intuitively  as  the  infant  shows  appre- 
ciation of  sounds  of  higher  pitch,  which  are  now  necessary  for 
the  development  of  the  intricate  terminal  nervous  elements  of 
the  cochlea.  It  may  be  observed,  also,  that  this  change  of 
tones  becomes  necessary  in  order  to  quiet  the  child,  by  lessen- 
ing the  effect  of  the  other  sonorous  disturbing  elements,  which 
increase  as  the  infant's  senses  become  more  acute. 

The  organs  of  sense  of  the  infant,  like  those  of  the  young  of 
many  of  the  mammalia,  are  capable  of  educational  development 
in  proportion  to  their  individual  tuition  and  the  perfection 
reached  in  the  design  of  the  intricate,  delicate  portions  of  these 
organs.  In  all  animals  sight  and  hearing  are  susceptible  of 
more  rapid  development  under  early  and  careful  educational 
endeavors  than  other  organs  of  sense.  The  circumstances  which 
surround  the  infant,  or  the  direction  of  the  educational  effort 
toward  one  organ  or  the  other,  may  tend  toward  the  devel- 
opment of  the  retentive  memory  of  the  auditory  sphere  over 


120  THE  DISEASES  OF  CHILDREN. 

that  of  the  optical  center.  There  seems  to  be  little  doubt^ 
however,  that  when  developmental  conditions  are  equal,  special 
education  of  the  retentive  powers  of  one  sphere  may  enable  it 
to  surpass  the  other.  It  is  not  improbable  that  the  infant 
learns  to  recognize  the  eyes,  and  perhaps  the  face  of  the  mother 
and  her  voice,  before  either  the  face  or  voice  of  the  father, 
the  child  seeming  to  retain  the  memory  of  the  mother,  not  only 
from  more  intimate  relation,  but  because  the  visual  and  sound 
associations  of  her  are  more  frequently  impressed. 

The  lullaby  common  to  all  races  contains  from  an  ethnolog- 
ical standpoint  an  interesting  rhythmic  scale  exhibited  in  the 
folk-lore  of  all  races,  and  while  its  purpose  is  to  induce  sleep  of 
the  infant,  at  the  same  time  it  affords  the  stimulus  necessary 
for  the  development  of  its  auditory  power.  In  the  early  period 
of  infancy  the  tones  of  the  sleep-song  can  produce  only  the  slight- 
est and  most  evanescent  impression  upon  the  auditory  sphere 
of  the  child's  brain,  and  yet  be  suflficient  to  accomplish  their 
purpose.  In  the  study  of  the  probable  extent  of  the  hearing^ 
power  of  the  infant,  we  find  that  the  value  of  our  observations 
is  lessened  by  possible  effect  of  motion  to  which  the  child's  head 
is  subjected,  in  the  effort  to  quiet  it.  The  lullabies  of  any  tongue 
seem  often  ineffectual  unless  accompanied  by  rocking,  or  other 
motions  of  the  mother  or  attendant,  which  are  transmitted  to  the 
infant  in  its  early  life,  when  in  the  arms,  lap  or  upon  the  back. 
The  Indian  squaw,  with  her  crying  papoose  upon  her  back, 
rarely  stops  to  croon  a  lullaby,  but  shortens  her  steps,  and 
with  a  lifting  motion  of  the  body  soon  provokes  a  somnolent 
condition  of  her  offspring.  The  Javanese  father,  with  his  infant 
swinging  below  his  chest  in  a  sash  hammock,  hastens  his  step 
at  the  cry  of  the  child  and  thus  quiets  it.  The  disturbance  of 
the  fluid  in  the  semicircular  canals  of  the  ear,  and  the  effect 
upon  what  might  be  termed  the  equilibrium  sense  of  the  child 
thus  produced,  may  explain  the  apparent  more  potent  effect  in 
the  production  of  sleep-anesthesia  than  that  derived  from  the 
most  musical  lullabies. 

Perhaps  there  may  be  an  analogous  confirmation  of  the  the- 
ory presented  in  consideration  of  the  fact  that  whenever  prac- 
ticable, the  music  which  produces  a  quickened  step  in  military 
life  carries  the  soldiers  on  to  victory,  perhaps  because,  in  addition 
to  their  patriotism,  their  thought  of  self  is  diminished  by  the 
effect  produced  upon  the  function  of  the  semicircular  canals  of 
their  auditory  apparatus. 

Care  of  the  Ears. — The  question  is  often  asked  of  both 
physician  and  aurist  what  should  be  done  in  the  way  of  the 
hygiene  of  the  ears  and  their  protection  from  disease.     The 


CAUSES  OF  EAR  DISEASES.  121 

ears  of  the  infant  when  normal  require  no  attention  except  that 
necessary  for  the  cleanliness  or  protection  of  the  auricle ;  nature 
has  provided  every  requisite  for  the  proper  care  of  the  canal. 
The  washing  of  the  external  ear  is  as  necessary  as  that  of  any 
other  portion  of  the  child's  anatomy  ;  but  beyond  this  external 
appendage  it  is  both  unwise  and  oftentimes  dangerous  to  go. 
In  the  effort  to  cleanse  what  appears  unclean,  the  auditory 
canal  may  suffer  injury  from  the  attempt  to  remove  the  nat- 
ural ceruminous  protective  covering  of  the  walls  of  the  canal. 
Attention  should  more  often  be  given  to  the  coverings  of  the 
head  and  throat,  as  undue  exposure  of  those  parts,  more  fre- 
quently in  climates  of  rapid  changes  like  ours,  result  in  many 
ear  affections ;  hence  it  is  well  in  children  to  provide  for  the 
head,  ears  and  throat  a  light,  soft  and  warm  covering  during 
the  fall,  winter  and  spring  months.  In  the  washing  of  the  ears 
it  is  not  necessary  nor  well  to  manipulate  the  auricle  too  much, 
in  the  way  of  pulling,  digging  or  dragging  it,  as  while  it  may 
not  be  especially  delicate  of  itself,  its  relation  to  the  middle 
ear  is  very  close  and  unnecessary  efforts  expended  upon  it 
oftentimes  produce  deeper  changes  which  affect  both  the  com- 
fort and  hearing  of  the  child. 

Washing  and  wetting  the  head  and  hair  of  the  child  is  often 
deleterious  to  its  ears,  particularly  so  in  those  children  who  ex- 
hibit an  ear-disease  tendency  and  should  only  be  indulged  in 
under  the  most  favorable  circumstances  and  when  the  care  taken 
is  such  as  may  prevent  the  accession  of  cold. 

Boxing  or  pulling  the  ears  of  the  child,  while  not  only  cruel, 
is  likely  to  be  followed  by  disturbances  of  the  drum-head  and 
middle  ear  which  cause  inflammation,  affect  the  hearing  and 
may  endanger  life. 

When  the  ear  is  in  a  normal  condition  water  should  not  be 
introduced  into  it  by  means  of  a  syringe  or  in  any  other  way,  as 
it  tends  to  produce  not  only  discomfort  but  disease,  and  by 
moistening  the  drum-head  lessens  the  hearing  at  least  tempo- 
rarily and  often  permanently. 

Causes  of  Ear  Diseases  in  Children. — The  peculiar  and 
intimate  relation  existing  between  the  middle  ear  and  the  naso- 
pharynx, is  a  prime  factor  in  the  production,  during  the  first 
few  years  of  life,  of  the  great  numbers  of  ear  diseases.  The 
close  connection  of  the  ears  and  throat,  favors  the  disposition 
to  inflammatory  affections  of  the  middle  ears,  which  constitute 
the  larger  percentage  of  ear  diseases  occurring  in  infancy  and 
childhood.  The  mucous  membrane  lining  the  nasal  portion  of 
the  pharynx,  in  which  we  have  the  openings  of  the  eustachian 
tubes,  presents  in  childhood  a  normal,  tumid  condition,  and  is 


122  THE  DISEASES  OF  CHILDREN. 

spongy  from  the  rich  blood  supply  sent  to  it.  Between  the 
openings  of  the  tubes,  the  adenoid  tissue  reaches  its  highest 
development  in  the  third  or  pharyngeal  tonsil.  The  tendency 
is  always  great  in  every  coryza,  angina,  exanthem,  or  other 
disease  which  affects  the  nose,  throat  or  pharynx,  from  the  swell- 
ing and  inflammation  of  the  mucous  membrane  of  these  parts, 
toward  an  involvement  of  the  ears.  The  breathing  of  damp 
and  impure  air  may  exhibit  its  deleterious  effect  upon  the  nasal 
and  pharyngeal  mucous  membrane,  in  the  production  of  an  in- 
flammation, or  a  congestion  at  least,  of  the  mucous  membrane 
of  the  eustachian  tubes,  which  interferes  with  the  function  of 
hearing,  often  before  there  is  any  apparent  impairment  of  the 
child's  general  health. 

The  eruption  of  the  teeth  or  their  premature  decay  are  fruit- 
ful causes  of  ear  diseases  in  early  life.  As  the  process  of  denti- 
tion extends  over  a  number  of  years,  during  which  there  is  a 
disposition  to  sympathetic  irritation  of  the  ears,  aural  affections 
are  both  common  and  often  persistent. 

Too  frequent  bathing  of  the  infant,  or  its  exposure  to 
changes  of  temperature  soon  after  birth,  imperfect  drying  of 
the  hair  of  the  child  after  washing,  wetting  of  the  feet,  or  the 
retention  of  damp  clothing,  result  in  the  frequent  production 
of  hyperemia  and  inflammation  of  throat  and  nose,  which  may 
implicate  the  ears. 

In  this  climate  there  is  a  great  tendency  in  children  of  any 
age  to  catarrhal  conditions  of  the  nose  and  throat,  which  is  in- 
creased by  their  exposure  to  the  temperature  variations  often 
present  in  a  single  room;  the  room  may  be  too  hot  or  too  cold, 
often  the  atmosphere  is  too  dry  or  too  moist  for  the  individual 
child,  so  that  the  temperatural  and  the  hygrometrical  condi- 
tions of  the  air  of  its  surroundings  afford  a  frequent  cause  of  ear 
complication  or  the  aggravation  of  an  existing  catarrhal  affec- 
tion. 

The  close  proximity  of  the  brain  to  the  middle  ear  in  infancy, 
owing  to  the  very  intimate  connection  of  the  dura  mater  to  the 
mucous  membrane  of  the  tympanum,  gives  rise,  from  the  fre- 
quent variations  of  the  circulation  of  the  child's  brain  to  which 
it  is  subject,  to  the  production  of  hyperemias  and  inflammation 
of  the  middle  ear. 

In  infancy  the  commonest  causes  of  diseases  of  the  ear  may 
be  stated  to  be  the  acute  exanthemata,  dentition,  acute  catarrhs 
of  the  nose  and  throat,  diphtheria  and  hereditary  syphilis.  In 
childhood  and  with  older  children,  in  addition  to  the  above, 
typhoid  fever  and  pneumonia  furnish  frequent  ear  complica- 
tions, while  scarlet  fever  is  the  cause  of  the  destruction  of  more 
ears  than  all  the  other  causes  cited. 


ACUTE  CATARRH  OF  MIDDLE  EAR.  123 

Diseases  of  the  External  Ear.— Few  affections  of  the 
auricle  and  external  meatus  are  presented  except  when  eczema 
of  the  face  or  tinea  capitis  of  the  head  causes  by  extension  an 
implication  of  the  auricle,  or  when  either  disease  leaves  a  sub- 
acute inflammation  of  the  canal  within,  or  around  the  region  of 
ceruminous  glands,  so  that  a  discharge  is  present,  often  purulent 
in  character,  which  results  from  the  dermatitis.  Occasionally 
the  canal  is  the  seat  of  small  boils  in  the  ear  due  to  impaired 
nutrition. 

Acute  Catarrh  of  the  Middle  Ear. — Earache  is  the 
first  subjective  symptom  of  middle-ear  congestion  and  inflam- 
mation. Acute  catarrh  of  the  middle  ear  is  its  common  cause. 
It  is  rarely  present  in  infancy  or  childhood  from  such  causes  as 
reflex  neuralgias.  The  pain  varies  in  intensity  according  to  the 
extent  of  the  inflammatory  process  and  the  amount  of  pressure 
exerted  upon  the  walls  of  the  tympanic  cavity.  This  pain,  which 
is  deep-seated,  is  increased  on  pressure  below  the  auricle  or  by 
pulling  it.  Together  with  the  pain,  there  is  a  sense  of  fullness, 
deafness,  noises  in  the  ears  and  some  febrile  disturbances,  the 
latter  often  passing  unnoticed. 

Etiology. — Of  the  general  causes  mentioned,  as  producing  ear 
diseases,  coryza  is  the  most  common  of  those  of  the  acute  ca- 
tarrhs of  the  middle  ear,  although  all  other  causes  mentioned 
may  excite  it. 

Treatment. — As  the  earache  is  the  prominent  symptom,  the 
efforts  for  its  relief  are  mainly  in  the  direction  of  some  local 
medicament  applied  to  the  ear  canal.  Notwithstanding  the  fact 
that  the  practice  of  dropping  something  in  the  ear  on  the  ap- 
pearance of  earache  is,  and  always  has  been  a  common  one,  yet 
each  year  we  become  more  and  more  impressed  with  its  danger, 
its  unreliability  for  the  relief  of  the  pain,  and  the  fact  that  from 
its  indulgence  a  simple  attack  of  acute  hyperemia,  or  catarrh, 
which  should  be  self-limiting,  passes  into  a  more  severe  and  often 
chronic  affection  of  the  middle  ear. 

Relief  is  only  obtained  when  the  treatment  of  the  congestion 
or  inflammation  of  the  nares  and  naso-pharynx  is  followed  by 
the  removal  of  the  accompanying  swelling  of  the  eustachian 
tubes  and  middle  ear.  Our  efforts  should  be  directed  to  this 
portion  of  the  child's  head,  rather  than  to  the  local  medication 
of  the  outer  auditory  canal.  The  use  of  the  air-bag,  the  nozzle 
of  which  has  been  placed  in  one  nostril,  while  the  other  is  closed 
with  the  finger,  is  usually  sufficient  to  open  the  tubes,  clear  the 
tympanum  of  mucus,  and  often  relieves  the  earache  at  once. 

The  application  of  dry  heat  to  the  auricle,  canal,  or  side  of  the 
head,  by  means  of  a  hot  cloth,  a  hop-pillow,  or  a  hot-water 


124  THE  DISEASES  OF  CHILDREN. 

bottle  or  bag,  often  gives  immediate  relief,  or  lessens  the  in- 
tensity of  the  pain,  and  at  the  same  time  affords  the  safest  and 
best  of  topical  applications. 

We  have  at  our  command  a  number  of  homeopathic  reme- 
dies, such  as  aconite,  belladonna,  chamomilla,  calcarea,  dulca- 
mara, hepar  sulphur,  pulsatilla  and  mercurius,  which  exhibit 
remarkably  quick  results  in  dissipating  the  disease  when  prop- 
erly indicated. 

Acute  Suppurative  Inflammation  of  the  Middle 
Ear.  —  Acute  otitis  media  catarrhalis  by  its  terminology  is 
limited  to  such  inflammatory  conditions  of  the  tympanum  in 
which  only  serum  or  mucus  are  secreted  as  a  result  of  the  con- 
gestion or  inflammation  of  its  lining  membrane.  It  is,  however, 
always  the  pathological  precursor  of  the  suppurative  and  more 
destructive  inflammation  of  the  middle  ear,  and  from  which  it 
differs  only  in  the  intensity  of  the  symptoms  and  in  the  forma- 
tion and  collection  of  pus  instead  of  serum  or  mucus  in  this 
small  cavity.  As  in  all  cases  where  pus  forms,  a  corresponding 
destruction  of  tissue  accompanies  it ;  and  when  the  discharge 
from  the  ear  is  of  a  purulent  character,  we  should  recognize  its 
appearance  as  an  indication  that  a  more  dangerous  condition 
than  a  catarrhal  one  has  involved  the  ear,  with  danger  to  its 
tissues  as  well  as  to  the  hearing. 

When  pus  is  found  in  the  external  auditory  canal,  it  is  com- 
monly an  indication  of  a  rupture  of  the  drum-head,  due  either 
to  surgical  interference  (paracentesis),  or  the  result  of  nature's 
effort  to  relieve  the  pressure  of  the  imprisoned  pus  behind  it, 
and  to  lessen  the  danger  of  further  destruction  or  complication. 
Hence,  it  is  usually  symptomatic  of  the  presence,  or  prior  ex-^ 
istence,  of  a  suppurative  inflammation  of  the  middle  ear,  which 
has  destroyed  the  drum-head  to  a  sufficient  extent  to  enable  the 
discharge  from  the  tympanic  cavity  to  present  itself  in  the 
canal.  It  is  to  be  remembered  that  it  is  not  always  pathogno- 
monic of  middle-ear  disease,  as  it  may  be  accounted  for  by  an 
inflammation  or  ulceration  of  the  dermoid  and  osseus  portions 
of  the  external  auditory  canal.  During  infancy  or  childhood 
the  drum-head  is  much  less  dense,  ruptures  more  quickly  and 
easily,  and  shows  a  much  greater  reparative  power,  than  in 
adult  life. 

Etiology. — The  same  causes  which  produce  the  catarrhal  va- 
riety, are  still  active  in  the  suppurative  form.  Here,  liowever, 
scarlet  fever  is  the  most  prolific  of  all  causes,  measles  and  diph- 
theria being  next  in  order  of  frequency.  Sea  or  fresh-water 
bathing  is  responsible  for  a  large  number  of  cases  in  older 
children. 


ACUTE  S  UPP  URA  TI VE  IN  FLA  MM  A  TION.  125 

The  symptoms  are  the  same  as  those  of  the  acute  catarrhal 
form,  intensified.  The  pain  is  more  severe,  but  is  generally  re- 
lieved  by  rupture  of  the  drum-head,  and  the  consequent  dis- 
charge of  pus.  This  rupture  may  occur  within  a  few  hours 
after  the  attack  has  appeared,  or  more  frequently  after  the 
earache  has  lasted  two  or  three  days.  If  the  drum-head  is  ex- 
amined before  this  takes  place,  the  membrane  is  found  con- 
gested, dull,  soggy  in  appearance  and  bulging  outward ;  if  the 
examination  is  made  after,  the  canal  or  meatus  is  found  full  of 
pus.  If  the  pus  is  removed  from  the  canal  by  gentle  wiping 
with  absorbent  cotton,  or  gently  syringed  away,  the  point  of 
rupture  is  readily  seen  by  the  pulsation  which  is  presented  at 
the  spot. 

In  the  course  of  the  disease,  there  is  in  the  beginning  an 
acute  inflammation  of  the  eustachian  tube  which  causes  its  com- 
plete obstruction,  so  that  the  secretion  of  pus,  following  the  in- 
flammation which  has  already  passed  to  the  walls  of  the  middle 
ear,  not  being  able  to  find  an  outlet  by  way  of  the  tube  to  the 
pharynx,  is  confined  in  the  tympanic  cavity.  The  pressure 
thus  exerted  upon  the  walls,  tends  to  extend  the  inflammation 
upward  through  the  roof  and  involve  the  brain,  backward  to 
the  mastoid,  or  distends  the  drum-head,  and  at  the  same  time 
softens  it  by  the  inflammatory  products  thrown  into  it,  until  it 
finally  gives  way  with  a  greater  or  lesser  destruction  of  its 
tissue.  The  size  of  the  opening  thus  made,  may  vary  from  the 
most  minute  rupture,  to  complete  destruction  of  the  whole 
drum-head ;  as  a  rule,  the  extent  of  the  rupture  or  destruction 
being  greatest  where  the  inflammation  is  accompanied  by  im- 
poverished blood,  as  in  those  malignant  cases  of  scarlet  fever, 
diphtheria  and  measles,  when  the  destructive  process  usually 
involves  all  the  essential  portions  of  the  middle  ear. 

Treatment. — While  both  the  acute  catarrhal  and  the  suppur- 
ative forms  of  inflammation  of  the  tympanic  cavity  tend,  like 
many  other  acute  diseases  toward  recovery,  when  the  discharge 
does  not  cease  or  the  ruptured  membrance  heal  within  the  first 
week  or  two  following  the  attack,  the  result  is  to  produce  a 
chronicity  which  increases  with  the  age  of  the  child.  Hence, 
the  earlier  the  treatment  is  applied,  which  carries  with  it  a  full 
knowledge  of  the  condition,  after  a  proper  and  careful  examina- 
tion has  been  made  of  the  ear,  the  better  the  result  in  repara- 
tion of  the  lost  tissue  of  the  membrane  of  the  drum-head,  and 
the  restoration  of  the  hearing  function  as  well  as  the  preven- 
tion of  a  chronic  condition  of  the  middle  ear,  which  may  men- 
ace the  life  of  the  child  and  destroy  or  lessen  its-  hearing  at 
any  period  of  its  subsequent  life.  . 

The  belief,  which  has  been  so  common  in  the  past,  both 


126  THE  DISEASES  OF  CHILDREN. 

among  physicians  and  the  laity,  owing  to  their  ignorance  of  the 
pathological  conditions  of  the  ears  in  these  cases,  that  the  child 
would  outgrow  the  discharge  from  the  ear,  has  caused  deafness 
and  death  in  thousands  of  cases,  when  proper  treatment  might, 
at  an  opportune  time,  have  prevented  both.  In  many  cases, 
similar  results  have  occurred  from  ill-advised,  or  too  vigorous, 
treatment  in  cleansing  the  ears  with  the  syringe,  or  by  the  ap- 
plication of  the  various  preparations  which  are  intended  to  con- 
trol the  discharge. 

In  the  majority  of  cases  of  both  the  catarrhal  and  suppura- 
tive variety  of  middle-ear  diseases  occurring  in  children,  it  is 
usually  only  necessary  to  remove  as  far  as  possible  the  dis- 
charge by  wiping  the  more  external  portion  of  the  canal  with 
a  swab  of  absorbent  cotton  and  the  application  of  a  little 
boracic  acid  to  render  the  secretion  less  septic.  The  use  of  the 
syringe  and  the  accompanying  water  with  its  disinfectant  or 
antiseptic  solution  added,  while  washing  away  the  pus  at  the 
same  time,  unless  the  canal  and  drum-head  are  carefully  dried 
with  the  cotton-swab  under  a  good  illumination  of  the  canal 
and  drum-head,  results  in  the  retention  of  a  portion  of  the  fluid 
which,  if  not  already  warmed,  as  all  solutions  introduced  into 
the  ear  should  be,  soon  becomes  of  the  temperature  of  the 
surrounding  parts,  and  the  elements  of  a  poultice,  heat  and 
moisture,  are  presented  to  the  tissues ;  this  is  followed  by  more 
or  less  maceration  with  consequent  stasis  in  the  circulation  and 
a  retardation  of  the  healing  process,  and  at  the  same  time  tends 
toward  the  extension  of  the  ulcerative  process  and  further  de- 
struction of  tissue. 

During  the  last  ten  or  twelve  years,  with  a  better  knowledge 
and  a  wider  experience  in  the  treatment  of  both  the  acute  and 
chronic  suppurations  of  the  middle  ear,  results  of  treatment  of 
those  conditions  have  been  much  more  brilliant  and  satisfactory 
than  those  of  the  years  before.  The  substitution  of  the  dry 
for  the  moist  treatment,  the  introduction  of  boric  acid,  resorcin, 
peroxide  of  hydrogen  and  other  topical  remedies  to  our 
armamentarium  have  largely  increased  our  percentage  of  cures 
over  former  years. 

As  the  acute  form  tends  so  often  to  become  chronic,  we 
shall  find  that  it  is  only  after  the  nose  and  naso-pharnyx  have 
received  proper  treatment,  and  all  anomalous  conditions  there 
presented  are  removed,  that  the  ear  disease  responds  promptly 
to  treatment,  relapses  do  not  occur  as  before,  and  a  permanent 
cure  of  the  inflammation  and  its  accompanying  discharge  is 
secured. 

Prognosis. — This  is  not  so  favorable  as  in  the  non-suppura- 
tive  variety,  but   the  early  intervention  of  proper  treatment 


CHR  ONIC  S  UPP  UP  A  TI VE  IN  FLA  MM  A  TION.         127 

renders  the  prognosis  much  more  favorable  than  is  generally- 
supposed.  The  majority  of  uncomplicated  cases  occurring  in 
otherwise  healthy  children  terminate  in  complete  recovery. 
When  during  scarlet  fever,  measles  or  diphtheria  this  affection 
appears  as  a  complication,  the  prognosis  is  usually  bad,  as  the 
destruction  of  the  parts  of  the  ear  is  often  extensive,  with 
greater  tendency  to  the  formation  of  adhesions  and  extension 
of  the  ulcerative  process,  owing  to  the  lowered  vitality  of  the 
febrile  condition. 

Results. — Recovery  with  complete  or  partial  restoration  of 
the  hearing  power.  Chronic  suppuration ;  mastoid  complica- 
tion ;  periostitis,  necrosis  and  caries  of  the  temporal  bone  ; 
meningitis  ;  cerebral  abscess ;  pyemia  and  death. 

When  in  the  opinion  of  the  medical  attendant  it  is  deemed 
advisable  to  perform  paracentisis  of  the  drum-head,  the  most 
bulging  portion,  which  is  usually  found  to  be  the  lower  poste- 
rior segment,  should  be  selected  for  puncture.  With  a  good 
illumination  of  the  parts  a  paracentisis  knife  is  carried  through 
the  membrane,  and  upon  the  withdrawal  of  the  knife  a  quantity 
of  pus  follows  through  the  perforation,  usually  with  considera- 
ble relief  of  both  the  pain  and  the  inflammation. 

In  the  internal  medication  for  acute  suppurative  otitis  media 
we  find  such  remedies  as  aconite,  belladonna,  calcarea  carb.,  fer- 
rum  phos.,  hepar  sulph.,  mercurius,silicea  and  sulphur  affording 
good  results  from  their  exhibition. 

Chronic  Suppurative  Inflammation  of  the  Middle 
Ear. — This  is  one  of  the  most  common  affections  of  the  ear  oc- 
curring during  childhood,  almost  all  cases  in  which  there  is  a  dis- 
charge from  the  ear  being  due  to  this  disease.  It  is  usually  the 
sequel  of  the  acute  form,  but  cases  present  themselves  in  which 
a  tendency  to  chronicity  may  be  said  to  be  exhibited  in  the  be- 
ginning, as  in  those  cases  occurring  in  tuberculous  subjects,  or 
when  they  are  the  accompaniment  of  pulmonary  phthisis. 

Etiology. — Scarlet  fever,  measles  and  diphtheria  form  the 
most  frequent  causes,  as  during  the  acute  period  of  the  ear 
attack,  the  destruction  of  tissue  has  perhaps  been  great,  the 
vitality  of  the  parts  so  lowered  by  the  impoverished  blood 
occasioned  by  the  general  disease  that  the  healing  tendency 
is  very  much  diminished.  Abnormal  conditions  of  the  nose 
and  upper  pharynx  when  present  tend  to  cause  the  acute 
variety  to  pass  to  the  chronic,  notwithstanding  the  aural 
treatment. 

Symptoms  and  Diagnosis. — The  discharge  of  pus  from  the 
ear  is  the  common  symptom.  The  quantity  varies  in  amount 
from    that    just   suf^cient   to   moisten   some   portion  of   the 


128  THE  DISEASES  OF  CHILDREN. 

walls  of  the  tympanic  cavity  to  constant  flow  from  the  ear, 
which  fills  the  canal  and  flows  down  the  neck  or  face.  There 
are  cases  in  which  the  pus  found  in  the  middle  ear  passes 
through  the  eustachian  tube  and  is  discharged  into  the  throat 
and  finally  find  its  way  into  the  stomach.  Deafness  is  always 
present,  varies  in  degree,  from  an  almost  inappreciable  loss  to 
total  deafness.  This  variation  is  not  dependent  upon  the  size 
or  location  of  the  perforation,  but  upon  the  changes  which 
have  affected  the  tension  and  mobility  of  the  drum-head.  The 
ears  are  rarely  complained  of;  pain  is  exceptional,  unless  there 
is  an  acute  exacerbation  of  the  disease. 

The  character  of  the  discharge  is  dependent  upon  the  condi- 
tion of  the  tympanic  cavity  and  meatus.  The  pus  in  a  typical 
case  is  then  laudable,  and  as  the  parts  heal  the  secretion  be- 
comes more  thin  and  scanty.  When  mixed  with  mucus  it  is 
stringy  and  hard  to  remove.  When  the  mucous  membrane  of 
the  middle  ear  is  denuded  of  its  epithelium,  very  much  swollen, 
or  granulatious  and  soft  polypi  appear  upon  its  surface,  the 
discharge  is  often  mixed  with  blood.  The  odor  of  the  discharge 
depends  somewhat  upon  the  care  given  the  ear ;  where  the  pus 
is  allowed  to  remain  and  the  ears  are  neglected  it  becomes  very 
fetid.  When  the  odor  is  bad  in  cases  where  proper  cleanliness 
is  indulged  in,  it  is  usually  due  to  a  diseased  condition  of  the 
bone,  and  it  is  particularly  indicative  of  this  when,  in  addition 
to  its  fetor,  it  presents  a  brownish  color.  Occasionally  the  dis- 
charge is  made  fetid  by  admixture  with  an  altered  secretion  from 
the  ceruminous  glands. 

Perforation  of  the  membrane  of  the  tympanum  is  the  almost 
invariable  accompaniment  of  chronic  suppuration  of  the  middle 
ear.  The  presence  or  absence  of  the  opening  alone  enables  us 
to  determine,  when  pus  is  found  in  the  canal,  whether  the  con- 
dition is  one  of  middle-ear  disease  or  a  diseased  condition  of 
the  canal.  To  determine  its  presence  or  absence  the  canal  must 
first  be  cleaned  of  any  discharge,  the  deeper  parts  of  the  ear 
well  illuminated,  when,  if  the  perforation  is  of  any  extent,  it  is 
readily  distinguished  by  the  appearance  of  the  reddish  mucous 
membrane  lining  the  inner  wall  of  the  drum  cavity  in  the  white 
frame  afforded  by  the  remaining  portions  of  the  drum-mem- 
brane. When  the  opening  is  very  small  it  is  only  detected  by 
forcing  air  through  the  nostril  by  some  method  of  inflation 
when,  passing  through  the  opening,  a  whistling  sound  is  heard. 

The  size  and  shape  of  the  perforation  varies  greatly,  from  the 
most  minute  opening  to  that  of  complete,  or  almost  complete, 
loss  of  the  entire  membrane.  It  is  usually  located  in  the  lower 
and  posterior  portion  when  of  moderate  size,  and  when  very 
large  commonly  involves  the  lower  half.     The  relation  of  the 


CHRONIC  SUPPURATIVE  INFLAMMATION.         129 

size  or  location  of  the  perforation  to  the  loss  of  hearing,  as  al- 
ready stated,  is  a  difficult  one  to  determine  on  inspection.  In 
proportion  as  the  opening  lessens  or  changes  the  tension  of  the 
drum-membrane,  or  the  inflammation  which  caused  it  has  dis- 
turbed the  mobility  of  the  ossicles,  is  the  hearing  power  dimin- 
ished. If  neither  the  tension  nor  the  free  movement  of  the  os- 
sicles is  interfered  with  by  the  perforation,  no  serious  deafness 
accompanies  it. 

The  sequelas  mentioned  under  the  acute  suppurative  process 
are  to  be  noted  as  occurring  more  frequently  under  the  chronic 
form.  Such  complications  always  render  the  prognosis  very 
grave,  both  as  regards  life  and  hearing. 

The  prognosis  in  the  majority  of  cases,  with  the  improve- 
ment in  our  methods  of  treatment,  is  much  more  favorable 
than  formerly,  ^ut  as  the  condition  is  always  a  serious  one  and 
as  long  as  it  exists  is  a  menace  to  life,  our  prognosis  must  be 
guarded. 

Treatment. — The  whole  effort  in  the  treatment  is  to  be 
directed  toward  the  restoration  of  the  tissues  of  the  middle  ear 
to  a  healthy  condition  ;  when  this  is  accomplished  the  discharge 
usually  ends.  The  improvement  in  the  condition  of  the  tissues 
is  usually  followed  by  a  healing  of  the  perforation  when  the 
opening  has  not  been  too  large.  The  return  of  the  ear  to 
health  restores  the  hearing  in  whole  or  in  part,  but  continued 
treatment  is  usually  necessary  to  improve  the  hearing,  when 
deficient,  by  lessening  the  adhesions  and  other  changes  which 
have  occurred  in  the  ear  as  a  result  of  the  prolonged  suppura- 
tion. In  the  treatment  it  is  necessary  to  have  the  discharge 
removed  with  sufficient  frequency  to  prevent  the  maceration 
of  the  membrane  with  which  it  comes  in  contact.  As  already 
suggested,  this  is  better  accomplished  by  the  dry  method  in 
which  swabs  of  absorbent  cotton  are  used  to  remove  it.  There 
are  some  cases,  however,  in  which  the  syringe  is  better  indi- 
cated, and  after  its  use  all  the  moisture  left  in  the  ear  should 
be  absorbed  by  cotton  introduced  for  the  purpose.  The  inven- 
tion of  peroxide  of  hydrogen  and  its  effect,  when  used  in  the 
ear  by  thoroughly  removing  and  destroying  the  purulent 
secretion,  has  done  more  than  any  other  remedy  in  aural  thera- 
peutics to  increase  the  percentage  of  cures  in  these  cases. 
When  the  discharge  has  been  thoroughly  removed,  it  has  been 
customary  to  apply  some  astringent  solution  or  powder  to  the 
inflamed  surfaces.  There  seems  to  be  a  consensus  of  opinion 
of  the  otologists  of  to-day  that  the  application  made  should  be 
dry,  and  of  the  great  variety  of  powders  used  in  this  way, 
boracic  acid  presents  superior  claims.  In  the  use  of  boracic 
acid  the  amount  applied  should  vary  with  the  quantity  of  dis- 
D.  C— 9 


130  THE  DISEASES  OF  CHILDREN. 

charge.  If  the  discharge  is  full  and  free,  the  external  canal 
should  be  filled  with  it ;  and  as  the  discharge  becomes  less  under 
treatment,  it  is  better  not  to  pack  the  passage  with  the  powder, 
as  it  is  then  more  likely  to  cake  and  form  a  hard  plug  which  is 
removed  with  difficulty  and  which,  when  in  situ,  may  cause 
serious  trouble  by  confining  the  pus  in  the  middle  ear.  The 
frequency  of  its  application  depends  upon  the  quantity  of  the 
discharge  and  it  may  require  daily  repetition  of  the  process. 
Its  introduction  into  the  ear  is  readily  accomplished  by  the  use 
of  the  common  powder-blower. 

After  the  process  has  been  finished,  a  small  wad  of  cotton 
should  be  placed  in  the  ear  to  prevent  the  powder  falling  out, 
and  also  afford  protection  to  the  tympanum  from  atmospheric 
changes.  Proof  alcohol  may  sometimes  be  applied  to  the  tissues 
of  the  middle  ear  with  good  effect. 

Where  exuberant  granulations  or  polypi  spring  up  during  the 
course  of  the  disease,  they  should  be  removed  by  the  application 
of  caustics,  such  as  nitrate  of  silver,  resorcin,  chromic  acid,  bi- 
chromate of  potash  or  perchloride  of  iron,  as  may  seem  indi- 
cated from  experience  for  the  individual  case.  The  greatest 
care  should  be  taken  in  their  use  to  prevent  destruction  of  good 
tissue  and  to  limit  their  action  to  that  portion  which  we  wish 
to  destroy.  When,  as  in  case  of  polypi,  the  mass  is  too  large 
to  be  rapidly  reduced  by  applications  of  caustics  or  astringents, 
the  use  of  a  wire  snare  or  the  curette  becomes  necessary. 
After  granulations  have  been  destroyed  or  the  polypi  removed, 
it  is  necessary  to  treat  the  part  from  which  they  were  developed 
until  it  has  become  covered  with  epithelium  or  scar-tissue^ 
which  prevents  their  recurrence. 

Mastoid  complication  is  very  rare,  except  that  superficial  form 
which  exhibits  itself  as  an  abscess  over  the  mastoid  portion  of 
the  temporal  bone.  As  the  mastoid  cells  do  not  develop  much 
before  the  age  of  puberty,  we  do  not  have  the  dread  complica- 
tion of  true  mastoiditis  to  deal  with,  as  in  adult  life.  The  skin 
over  the  mastoid  often  becomes  tumid,  red  and  the  part  pain- 
ful, and  pus  forms  beneath  the  skin  or  periosteum  covering  the 
rudimentary  cells  of  the  mastoid,  and  requires  only  moderate 
poulticing  until  the  abscess  may  be  lanced  with  relief  to  the 
imprisoned  pus  without  the  more  extended  operation  necessary 
in  later  life,  which  requires  the  opening  of  the  bone  cells. 

If  the  single  cell  or  antrum  of  the  child's  undeveloped  mas- 
toid becomes  inflamed  and  pus  forms,  the  abscess  tends  to  dis- 
charge itself  through  the  thin  cribriform  outer  plate  of  the 
rudimentary  mastoid,  and  point  in  the  softer  tissues  covering  the 
part. 

Periostitis,  caries  and  necrosis  require  attention  during  the 


CHR  ONIC  NON-S  UPP  URA  TI VE  CA  TA  RRH.  3  31 

course  of  the  treatment  of  chronic  suppuration  as  they  appear, 
but  like  other  sequela  already  mentioned  as  complications  of 
the  disease,  they  require  such  care  that  the  discussion  of  their 
treatment  would  be  out  of  place  in  a  chapter  devoted  to  the 
consideration  of  those  more  common  diseases  of  the  ear  occur- 
ring in  children. 

The  general  health  of  the  child  must  in  all  cases  receive  due 
consideration  ;  proper  hygiene  and  improved  nutrition  are  the 
greatest  of  aids  in  the  effort  to  cure  this  disease.  We  often  find 
these  patients  suffering  from  dyscrasias,  or  low  conditions  per- 
haps due  to  malnutrition,  and  before  attempting  to  cure  the 
ear  disease  we  shall  save  time  if  we  will  devote  attention  to 
those  measures  which  would  result  in  the  improvement  of  the 
general  health.  A  proper,  and  often  a  specially  nutritious,  diet, 
fresh  air,  and  the  improvement  resulting  from  them  will  again 
and  again  indicate  to  us,  that  the  ear  is  only  a  part  of  the  whole, 
and  that  the  condition  of  the  part  depends  in  its  local  affection 
upon  the  condition  of  the  whole. 

When  we  have  removed  the  exciting  causes  as  far  as  found, 
or  improved  the  ear  condition  as  far  as  possible  by  such  local 
measures  as  may  be  expedient,  we  should  look  closely  into  the 
symptoms,  both  local  and  general,  which  may  give  us  the  indica- 
tion for  the  prescription  of  the  homeopathic  remedy  which  will 
result  in  the  curing  of  cases  which  otherwise  would  go  on  to 
further  destruction. 

Among  the  remedies  which  may  be  indicated,  there  are  few 
in  addition  to  those  already  mentioned  under  the  head  of  the 
acute  variety  ;  but  it  will  be  well  in  cases  of  doubt  to  read  care- 
fully the  general  aural  indications  of  the  more  common  reme- 
dies, which  may  be  indicated  in  ear  diseases,  and  which  are 
found  on  page  141. 

Chronic  Non-suppurative  Catarrh  of  the  Middle 
Ear. — This  disease  has  for  its  most  significant  symptom  an 
impairment  of  the  hearing.  The  deafness,  while  not  always 
readily  recognized,  is  more  or  less  marked,  or  may  even  be  com- 
plete,  long  before  there  is  more  than  a  suspicion  of  the  defect 
arising  in  the  minds  of  the  child's  attendants.  Its  beginning 
in  children,  as  well  as  in  adults,  is  so  insidious  that  it  is  only 
brought  into  recognition  and  relief  sought,  when  the  deafness 
arising  from  it  is  so  great  as  to  become  sufficiently  noticeable, 
and  to  call  into  question  the  want  of  proper  intellectual  devel- 
opment for  the  child's  age.  The  child  may  show  slow  or  no 
response  to  calls  or  queries  addressed  to  it  in  the  ordinary  tones 
of  conversation ;  when  its  age  is  such  that  otherwise,  from  a 
normal  hearing  apparatus  and  well-developed  function,  it  should 


132  THE  DISEASES  OF  CHILDREN. 

be  able  to  respond  properly  to  the  interrogative  sound  impres- 
sions which  are  directed  to,  and  impressed  upon  it. 

Symptoms. — The  deafness,  which  varies  from  day  to  day,  and 
is  worse  frequently  when  the  weather  is  damp  or  cold,  or  from 
coryzas  which  assail  the  child,  presents  the  most  common 
symptom. 

Subjective  noises  in  the  ear  are,  in  the  child  suffering  from 
this  affection,  rarely  spoken  of,  except  in  older  children,  and 
efven  then  only  when  questioned  as  to  their  presence.  The 
sounds  as  noticed  by  children  are  usually  of  a  singing  or  ring- 
ing character,  and  are  often  absent  entirely ;  or  a  crackling 
sound  on  swallowing  is  described.  The  more  frequent  cause 
of  complaint  is  that  the  voice  sounds  are  like  those  which  are 
produced  by  many  talking  in  a  room ;  in  fact,  sounds  are  con- 
fused, and  there  is  no  clear  conduction  or  proper  reception. 

The  examination  of  the  canal  and  of  the  external  meatus 
reveals,  perhaps,  a  want  of  cerumen  or  a  hyper-secretion  of  it. 
The  latter  is  the  more  common  condition  in  youth,  while  its 
absence  is  the  usual  accompaniment  of  the  same  condition  of 
the  middle  ear  in  the  adult. 

The  drum-head  exhibits  changes  in  position  and  appearance, 
and  when  retracted  it  presents  a  dimness  of  color,  or  loss  of 
brilliancy  reveals  to  us  the  changes  which  have  occurred  in  the 
middle  ear,  and  which  account  for  the  loss  of  hearing  in  the 
individual  case. 

In  children  old  enough  to  talk,  the  vowel  sounds  are  often 
mistaken  for  the  consonants,  or  mistakes  are  made  in  the  repe- 
tition of  words  during  the  testing  of  the  hearing,  as  "  pin  "  for 
"  man,"  or  '*  man  "  for  "  pin  ;  "  or  "  four  "  for  "  more."  And  it 
will  often  be  found  that  the  hearing  is  so  deficient,  that  words 
are  only  properly  repeated  by  the  child  when  pronounced  in  a 
loud  tone  within  a  few  feet  or  inches  of  its  ears. 

Earaches  occur  as  the  result  of  an  acute  exacerbation  of  the 
chronic  catarrh,  and  indicate  only  a  passing  increase  of  conges- 
tion of,  or  a  severe  inflammation  of  the  middle  ear. 

The  external  ear,  and  the  tissues  in  immediate  connection 
with  the  external  auditory  canal  are  often  sensitive  to  atmos- 
pheric cold,  to  touch  or  pressure,  or  the  necessary  manipulation 
undergone  during  the  washing  of  the  ears. 

Sneezing  is  not  uncommonly  an  accompanying  symptom  of 
catarrhs  of  the  middle  ear. 

Etiology. — The  causes  which  lead  so  often  to  affections  which 
produce  in  infancy,  childhood,  or  adult  life  direct  loss  of  hear- 
ing, have  been  considered  under  those  diseases  of  the  ear  al- 
ready discussed  in  this  chapter  under  the  topical  headings  of 
the  acute  and  chronic  suppurative  or  purulent  inflammations 


CHR  ONIC  NON-S  UPP  URA  TI VE  CA  TA  RRH.  1 33 

of  the  middle  ear.  In  the  chronic  affection  of  the  middle  ear, 
when  the  disease  presents  a  hypertrophy,  hypersecretion  of 
mucus,  or  a  thickening  of  the  membrane  lining  the  cavity  or 
enveloping  the  ossicles,  then  diseases  to  which  the  parts  have 
already  been  subjected  by  the  inflammatory  processes  enumer- 
ated, present  a  direct  and  indirect  causative  relation.  The  se- 
quela of  all  those  diseases  of  the  infant  or  child  which  it  has 
passed  through  may  leave  as  their  aftermath  an  impression 
upon  the  essential  portions  of  the  auditory  organ  which  finally 
result  in  a  deafness  too  often  progressive  and  complete.  The 
exanthemata  thus  produce  directly  or  indirectly  more  cases  of 
deafness  during  the  early  period  of  childhood  than  all  other 
diseases,  and  present  the  same  proportionate  causes  of  deafness 
in  the  adult. 

When  the  factors  just  mentioned  are  eliminated  from  statis- 
tics which  show  the  etiological  percentage  of  deafness,  we  find 
both  in  childhood  and  in  adult  life,  particularly  the  latter, 
that  the  loss  of  hearing  is  due  to  those  catarrhal  affections  of 
the  nose  and  naso-pharynx  which  are  so  common  in  our  cli- 
mate. One  may  become  as  fatigued  discussing  the  question  of 
possible  cure  of  general  catarrhs  as  he  does  of  the  consideration 
of  the  necessity  of  having  so  many  bespectacled  children  about 
us.  The  onset  of  a  catarrh,  which  invades  the  nose  and  throat 
and  involves  the  ear,  and  which  should  require  early  attention, 
is  so  often  unnoticed  in  the  beginning  that  it  is  only  when  the 
direct  affection  of  the  middle  ear  exhibits  a  marked  impairment 
of  the  hearing,  or  when  a  succession  of  colds  affecting  the  head 
which  are  accompanied  by  a  temporary  lessening  of  the  hearing- 
power,  finally  present  as  an  accumulative  effect  a  hearing- 
loss  which  is  sufficient  to  be  noticed  by  the  child's  attendants. 

When  the  child  suffers  from  recurrent  attacks  of  cold  con- 
fined in  its  expression  to  the  head  or  nose,  and  as  a  result 
breathes  through  its  mouth,  or  when  old  enough  its  articula- 
tion has  a  nasal  intonation,  or  its  hearing  power  is  questioned, 
the  examination  of  the  nose,  throat  and  ears  may  reveal  the 
cause  of  the  discomfort  of  the  child  and  the  condition  of  the 
ears  which  causes  its  deafness. 

There  can  be  little  doubt  that  heredity  as  well  as  climate  is 
a  predisposing  cause  of  catarrhal  middle-ear  affections  of  a 
chronic  nature,  with  progressive  changes  which  are  followed  by 
deafness. 

The  hygienic  conditions  of  our  houses,  the  defects  in  ven- 
tilation and  sanitation,  both  in  our  houses  and  the  schools  in 
which  we  live  or  place  our  children,  are  so  often  at  fault  that 
we  have  little  need  to  wonder  at  the  increasing  number  of  cases 
of  middle-ear  catarrh  which  daily  seek  treatment. 


134  THE  DISEASES  OF  CHILDREN. 

Prognosis. — The  course  of  the  disease  is  usually  slow ;  the 
variations  which  occur  in  the  mucous  membrane,  whether  one 
of  proliferation  or  of  atrophy,  finally  result  in  changes  that 
cause  a  retraction  of  the  drum-head,  the  stiffening  of  the  chain 
of  ossicles,  and  general  impairment  of  at  least  the  receptive 
and  conductive  portion  of  the  ear,  which  is  followed  by  a  pro- 
gressive loss  of  hearing. 

The  prognosis  in  childhood  is  far  more  favorable  than  in 
adult  life.  The  early  treatment  of  the  nose  and  throat  and 
the  direct  care  of  the  ears  cure  and  remove  the  chronic  ten- 
dency in  the  majority  of  cases  thus  treated. 

Treatment. — The  treatment  of  this  disease  depends  upon 
the  exciting  causes  which  have  given  rise  to  it  and  the  char- 
acter of  the  affection  of  the  tissue  of  the  middle  ear.  In  in- 
fancy and  childhood  the  catarrhs  of  the  nose  and  throat 
partake  of  the  hypertrophic  form,  wherein  there  is  a  moist 
rather  than  the  dry  catarrh  which  is  found  more  frequently 
later  in  life. 

An  examination  having  determined  the  form  of  catarrh 
which  involves  the  nose  and  throat,  we  proceed  to  relieve  that 
by  proper  treatment,  as  in  so  doing  we  remove  the  cause  of  the 
origin  of  the  middle-ear  affection  or  its  aggravation.  In  the 
treatment  of  these  parts  sprays  are  of  great  value,  the  me- 
dicinal components  of  them  depending  upon  the  particular 
condition  of  the  membranes  presented.  They  may  be  anti- 
septic, cleansing  or  therapeutic,  as  the  judgment  of  the  phy- 
sician may  deem  advisable.  Snufifing  fluids  up  the  nose  or  the 
use  of  the  nasal  douche  should  be  discontinued  by  every  medical 
adviser.  The  danger  of  exciting  acute  middle-ear  inflam- 
mations is  great,  as  when  the  fluid  passes  to  the  post-nasal 
portion  of  the  pharynx  the  involuntary  action  of  swallowing 
being  followed  by  an  opening  of  the  eustachian  tubes,  the 
fluid  is  carried  into  the  tube  or  into  the  middle  ear  and  an 
acute  inflammation  of  the  tympanic  cavity  is  the  result. 

Popular  catarrh  remedies,  which  from  their  advertisements 
should  enable  us  to  find  in  them  a  cure  for  all  cases  of 
catarrhal  deafness,  seem,  when  used,  to  increase  the  number  of 
aural  affections,  by  the  irritation  of  the  nose  and  naso-pharynx 
from  insufflation  of  the  powders  or  snufifing  up  the  fluids  of 
which  they  are  composed. 

As  the  air-passages  of  the  head  were  designed  for  the  purpose 
of  preparing  the  air  we  breathe  for  its  proper  change  in  the 
lung-tissue,  due  consideration  should  be  given  to  the  condition 
of  the  nose  and  throat,  and  at  the  same  time  the  after-effects 
which  a  too  vigorous  treatment  of  the  parts  may  have  upon 
the  welfare  of  the  child  in  regard  to  its  lungs  or  aural  organ. 


CHR  ONIC  NON-S  UPP  URA  TI VE  CA  TA  RRH.  135 

In  the  effort  to  remove  the  exciting  or  aggravating  causes 
of  this  disease,  there  is  much  to  consider  in  both  the  improve- 
ment of  the  hygienic  conditions  of  the  child  as  well  as  the 
treatment  which  is  to  be  directed  to  the  aural  condition. 

Whenever  there  is  a  chronic  ear  tendency,  as  evinced  by 
occasional  deafness  or  recurrent  attacks  of  ear-ache,  or  dis- 
charge from  the  ear,  the  clothing  of  the  child  is  to  be  inquired 
into,  as  well  as  its  nutrition.  Wet  feet  and  damp  clothing 
promote  diseases  of  the  aural  as  well  as  all  other  organs  of  the 
body.  In  our  climate,  which  from  the  writer's  observation,  is 
no  worse  than  others,  there  is  a  necessity  for  skin-protec- 
tion which  seems  from  experience  only  to  be  gained  by  the 
use  of  wool  underclothing  in  these  cases  during  all  seasons. 
The  adult  or  the  child  with  a  vigorous  constitution  may 
replace  its  flannels  with  cotton  as  the  season  advances  toward 
summer,  but  we  find  that  the  changes  from  heat  to  cold  to 
which  we  may  be  subjected  in  this  climate  provokes,  when 
the  skin  is  not  protected  by  a  garment  containing  in  its  com- 
position a  fair  proportion  of  wool,  both  aural  and  general 
catarrhs. 

W^hile  all  climates  may  have  their  defects  and  at  the  same 
time,  aggravate,  lessen,  or  cure  general  and  aural  catarrhs,  when 
the  question  is  asked,  Where  we  shall  take  our  child  that  it  may 
be  relieved  of  the  effect  of  the  sudden  changes  incident  to  its 
place  of  habitation,  or  avoid,  or  lessen  the  possible  climatic 
effect  upon  its  catarrhal  condition,  both  general  and  aural,  the 
climatologist  gives  only  a  general  rule,  which  does  not  enable 
us  to  answer  the  question  properly.  It  does  not  matter  always 
how  good  a  student  one  may  be  of  climato-therapy,  if  he  fails 
to  designate  as  the  particular  climate  in  this  country  or  others, 
or  the  precise  location  which,  from  its  altitude,  geographical 
position  and  average  temperature  reports,  would  seem  to  be 
best  for  the  individual.  No  specific  direction  can  be  given,  even 
Avhen  a  knowledge  of  the  local  catarrhal  condition  is  beyond 
doubt,  when  our  efforts  to  relieve  or  cure  the  condition  by 
change  to  other  climates,  are  followed  by  results,  which  should 
not  follow  from  statistical  reports  furnished.  We  may  advise 
that  the  patient  seek  in  Tennessee,  North  Carolina,  Georgia, 
Florida,  or  any  of  our  southern  states  of  the  east,  or  California 
in  the  west,  or  in  those  intermediate  climates  of  Arizona,  New 
Mexico,  or  Colorado,  which  may  furnish  that  particular  climate, 
with  its  proper  altitude,  lessened  humidity  of  atmosphere  and 
less  marked  changes  of  temperature,  which  we  hoped  will 
be  beneficial  to  him  and  prove  remedial  to  the  individual's  ca- 
tarrhal condition.  The  altitude  and  the  greater  dryness  of  the 
atmosphere,  due  to  geographical  location,  the  improvement  of 


136  THE  DISEASES  OF  CHILDREN. 

the  hygienic  surroundings,  which  latter  may  after  all  be  the 
most  beneficial  in  retarding,  limiting,  or  curing  this  progressive 
disease  of  the  middle  ear,  make  us  often  question  the  value  of 
the  climato-therapy. 

Adenoid  growths,  and  the  pharyngeal  tonsil,  when  much  en- 
larged, may  require  removal.  It  should  be  remembered,  how- 
ever, that  these  adenoid  bodies  and  the  enlarged  tonsil  tend 
toward  disappearance  before  puberty,  so  that,  except  when  they 
are  a  recognized  aggravation  of  the  aural  trouble,  from  direct 
pressure  upon  the  eustachian  tubes,  it  is  better  to  avoid  surgical 
interference,  as  the  attempt  to  remove  them  is  often  followed 
by  an  acute  inflammation  of  the  middle  ear,  with  the  result  of 
destroying  the  hearing  or  aggravating  the  aural  trouble. 

The  turbinate  bodies  often  present  a  turgescence,  which  in- 
terferes with  the  respiration.  They  are  not  always  the  cause 
of  the  mouth-breathing  which  may  be  present,  and  while  their 
swollen  condition,  due  to  their  tumidity,  may  impede  the  child's 
breathing,  it  is  not  always  necessary  to  remove  them  in  whole 
or  in  part  by  thermo  or  electro-cautery,  or  caustic  measures,  or  in 
any  other  manner,  as  their  enlargement  is  often  only  temporar)r 
and  we  should  consider  the  need  which,  both  as  child  and  adult, 
it  may  have  in  the  future  for  the  membrane  which  may  be  thus 
destroyed.  Time  will  probably  develop  the  fact  that  the  de- 
struction of  these  membranes  and  other  contiguous  portions 
have  much  to  do  with  the  individual's  future  systemic  economy. 
When  we  consider  that  a  pint  and  a  half  of  serum  is  secreted 
every  twenty-four  hours  by  the  mucous  membrane  lining  the 
nose  and  throat,  for  the  purpose  of  filtering,  moistening  and 
warming  the  air  we  breathe,  it  is  a  question  whether  these 
tissues,  which  nature  has  provided  for  the  proper  protection 
and  sanitation  of  the  lungs,  should  not  be  retained  as  they 
may  be  in  many  cases,  or  removed  or  destroyed  in  the  imme- 
diate effort  which  may  seem  necessary  for  the  temporary 
relief  which  perhaps  accompanies  such  measures.  Already 
from  my  observation,  cases  present  conditions  as  a  result  of 
surgical  interference  in  this  direction  which,  while  it  has  bene- 
fited the  child  at  the  time,  has  deprived  it  of  a  protection 
against  disease,  when  better  results  might  have  been  attained 
by  a  purely  medical  treatment. 

Where  the  hearing  becomes  so  impaired  from  any  cause  that 
the  child  no  longer  hears  the  tones  of  the  human  voice,  if  it 
is  under  five  years  of  age  its  powder  of  speech  is  also  lost,  hence, 
in  the  effort  to  prevent  deaf-mutism,  it  becomes  necessary  ta 
apply  the  treatment  as  early  as  possible.  In  these  cases,  while 
they  are  undergoing  the  treatment  for  the  aural  catarrh,  they 
should  be  compelled  to  keep  on  talking  and  not  be  allowed  ta 


INTERNAL  EAR. 


137 


resort  to  the  sign  language.  If  the  ear  trouble  can  be  even 
partly  cured,  there  is  a  very  fair  chance  of  their  retaining  their 
speech  under  these  circumstances. 

In  the  treatment  of  chronic  aural  catarrh,  it  is  imperative 
that  the  eustachian  tubes  and  the  tympanic  cavity  should  be 
thoroughly  inflated  with  air  after  the  method  of  Politzer.  The 
ordinary  air-bag  is  moderately  compressed  by  the  hand,  after 
the  nose-piece  of  the  bag  has  been  placed  in  one  side  of  the 
nose  and  the  other  side  closed  by  the  finger.  As  a  rule  the 
inflation  is  accomplished  in  the  majority  of  cases  with  little 
difficulty  ;  the  operation  clears  the  cavity  of  the  middle  ear  of 
serum  or  mucus,  replaces  the  drum-head  in  position,  and  is 
often  followed  by  a  marked  improvement  in  hearing,  which, 
however,  is  as  often  lost  before  the  succeeding  treatment  brings 
with  it  another  inflation.  As  the  condition  of  the  ear  im- 
proves, the  effect  of  the  inflation  is  more  lasting,  and  finally  in 
cases  which  are  cured  becomes  permanent. 

The  action  of  the  homeopathic  remedy  in  this  disease  is 
prompt  and  at  times  marvelous  in  cases  when  the  true  remedy 
is  prescribed.  The  remedies  which  are  more  frequently  indi- 
cated are:  arsenicum  ;  argentum  nit.  ;  aurum  mur. ;  belladonna, 
calcarea  carb. ;  calcarea  phos. ;  causticum  ;  ferrum  phos. ;  graph- 
itis  ;  hepar  sulph. ;  kali  mur. ;  kali  phos. ;  mercurius  dulc. ;  phos- 
phorus, etc. 

The  special  indications  will  be  found  in  the  general  list  of 
aural  remedies  given  on  page  97. 

Internal  Ear. — The  internal  ear,  or  labyrinth,  in  which  is 
lodged  the  delicate  mechanism  that  terminates  the  nerve  of 
hearing,  is  situated  just  beyond  the  middle  ear,  and  in  adult 
life  well  protected  by  the  solidification  which  comes  with  the 
full  development  of  the  temporal  bone.  It  is  readily  affected 
by  diseases  and  injuries  of  the  middle  ear,  and  also  of  the  brain, 
with  both  of  which  it  is  intimately  connected  during  child  life. 
The  temporal  bone,  not  having  reached  that  growth  and  com- 
pactness which  comes  in  later  years,  does  not  afford  that  pro- 
tection from  both  disease  and  injury  which  is  reached  later; 
hence  the  internal  ear  is  more  susceptible  to  diseases  which 
destroy  its  function  in  early  life  than  in  the  adult. 

The  concussion  of  the  head  from  blows  or  falls,  readily  com- 
municates its  effect  to  the  labyrinth  and  the  hearing  is  thus 
often  destroyed.  Such  diseases  as  cerebro-spinal  meningitis, 
mumps,  hemorrhagic  inflammation  of  the  internal  ear,  and  in- 
flammatory extensions  from  the  middle  ear  to  the  labyrinth  in 
scarlet  and  typhoid  fevers,  and  acute  or  chronic  suppurations 
of  the  middle  ear,  furnish  a  large  number  of  internal  ear  dis- 


138  THE  DISEASES  OF  CHILDREN. 

eases  which,  from  their  invasion  of  the  labyrinth,  destroy  the 
hearing  and  produce  in  the  younger  children  deaf-mutism. 

The  destruction  of  the  essential  portions  of  the  internal  ear 
are  not  rare  to  the  aurist,  although  much  less  so  to  the  general 
practitioner.  Of  the  causes  which  occasion  it,  twenty-five  per 
cent,  are  those  of  meningitis  and  cerebro-spinal  meningitis, 
while  scarlet  fever  presents  the  next  most  frequent  cause. 
These  diseases  produce  internal  ear  inflammations  by  direct 
extension  from  the  brain  or  middle  ear.  But  such  diseases  as 
small-pox  and  parotiditis  in  children,  also  produce  internal  ear 
complications  which  cause  destruction  of  the  auditory  nerve  or 
of  its  function.  Imperfect  development  of  the  internal  ear  due 
to  pre-natal  causes,  frequently  exhibit,  on  post-mortem  exami- 
nation,  sufficient  cause  of  the  infant's  deafness. 

The  symptoms  which  may  indicate  an  affection  of  the  in- 
ternal ear  in  infancy  or  early  childhood,  are  so  often  similar  to 
those  arising  from  affections  of  the  contiguous  parts,  that  it  is 
difficult  to  differentiate  between  the  symptoms  which  arise 
from  an  acute  inflammation  of  the  middle  ear  and  that  of 
the  internal  ear,  as  one  may  exist  alone  or  complicate  the 
other,  and  during  their  inflammatory  stage  simulate  those 
symptoms  which  are  presented  in  affections  of  the  meninges 
or  the  brain. 

In  children  too  young  to  express  the  location  of  their  suf- 
fering by  words,  we  may  thus  be  often  in  doubt  as  to  the 
organ  which  is  diseased.  The  cry  of  the  infant,  which  is 
always  a  symptom  of  discomfort,  if  not  of  disease,  should 
require  attention,  that  its  comfort  may  be  assured  and  the 
possible  disease  be  averted.  When  the  symptoms  of  affections 
of  more  remote  organs  have,  as  the  possible  cause  of  the 
child's  pain,  been  eliminated,  the  diagnosis  of  the  probable  ear 
or  brain  affection  becomes  a  necessary  consideration. 

One  often  finds  as  much  difficulty  in  distinguishing  the  "cri 
cephalique  "  of  meningitis  from  the  **  cri  "  occasioned  by  acute 
middle  and  internal  ear  disease,  as  he  does  in  determining  the 
value  of  those  symptoms  which  indicate  a  capillary  bronchitis 
or  pneumonia  in  infancy  when  their  possible  cause  is  due  to  a 
reflex  of  middle  or  internal-ear  inflammation,  until  an  exami- 
nation of  the  ear  is  made,  or  when  a  punctured  or  ruptured 
drum-head  gives  relief  to  the  sufferings  of  the  child  and  causes 
a  change  of  opinion  as  to  the  diagnosis  and  prognosis.  In  the 
infant,  as  we  are  dependent  upon  the  objective  symptoms 
for  our  diagnosis  and  prognosis,  the  close  study  of  the  symp- 
toms presented  enhance  both  their  diagnostic  and  prognostic 
value.  When  in  the  absence  of  marked  increase  of  temperature 
and  no  special  variation  in  the  digestion  or  the  action  of  the 


INTERNAL  EAR.  139 

bowels  the  infant  rolls  its  head  from  side  to  side  and  in  its  rest- 
lessness cries  out  in  that  tone  which  has  been  designated  the 
*'  head-cry,"  or  when  the  movement  of  the  head  by  the  attend- 
ant gives  evident  pain  to  the  child,  it  is  probable  that  an  im- 
plication of  the  ear  may  be  the  cause  of  its  suffering  rather 
than  an  affection  of  its  brain  or  other  portions  of  its  anatomy. 
The  loud  and  passionate  cry  of  the  infant,  together  with  the 
aggravation  from  movements  of  the  head  and  the  temporary 
relief  afforded  by  resting  the  head  upon  one  side  or  the  other, 
may  give  a  clue  to  the  real  affection.  For  example,  a  child 
is  attacked  with  a  sudden  fit  of  vomiting,  which  recurs  at  in- 
tervals during  the  several  succeeding  days  and  presents  a 
temperature  somewhat  above  the  normal  with  more  or  less 
marked  chill.  Within  the  first  twenty-four  hours  of  the  at- 
tack no  difficulty  in  hearing  is  noticed,  but  the  following 
day  brings  with  it  a  deafness  which  is  complete.  The  child's 
brain  remains  clear,  and  no  convulsions,  paralysis  or  opistho- 
tonos are  present.  In  a  week  the  child  recovers  its  appetite 
and  indulges  in  play,  but  it  is  noticed  that  there  is  complete 
deafness  and  that  there  is  also  an  unsteadiness  of  its  gait, 
and  it  requires  often  to  be  led  to  prevent  frequent  falls. 
We  examine  the  auditory  meatus  and  the  drum-head,  and 
find  no  variations  from  their  normal  condition  sufficient  to 
account  for  the  symptoms  presented.  The  close  study  of 
the  symptoms,  however,  are  followed  by  a  diagnosis  of  inflam- 
mation of  the  labyrinth.  We  must  differentiate  between 
this  affection  of  the  internal  ear,  which  might  be  termed 
idiopathic  and  that  which  results  from  hemorrhagic  inflam- 
mation, which  is  not  uncommon  during  the  infantile  period, 
and  those  arising  from  such  inflammatory  extensions  as  fol- 
low cerebro-spinal  meningitis,  injuries  and  complications  aris- 
ing from  diseases  of  the  middle  ear  alone,  or  accompanied 
by  those  diseases  which  affect  the  general  economy  of  the 
■child  as  well,  largely  by  the  history  as  well  as  the  symptoms 
presented  by  the  disease.  Such  drugs  as  quinia,  salicylic  acid, 
salicylate  of  soda,  salol  and  some  of  the  coal-tar  products  which 
have  come  into  such  prominent  favor,  have,  when  administered 
in  individual  cases,  produced  permanent  middle  and  internal- 
ear  changes,  which  have  been  followed  by  loss  of  hearing  and 
deaf-dumbness  as  well. 

The  destruction  of  the  auditory  nerve  or  its  function  from 
any  cause  in  children  under  the  age  of  seven  years  means  to 
the  child,  if  it  lives,  not  only  the  loss  of  audition  but  also 
that  of  whatever  power  of  expression  of  speech  it  may  have 
acquired  prior  to  its  deafness.  Unless  early  attention  is 
called  to  it  and  educational  treatment  followed,  the  possible 


140  THE  DISEASES  OF  CHILDREN. 

retention  of  the  vocal  expression  it  may  have  had,  or  the  ac- 
quirement of  the  power  of  speech  in  the  absence  of  audition, 
is  frequently  lost. 

While  treatment  of  the  ear,  both  local  and  internal,  may  be 
followed  with  some  gain  in  the  hearing  in  these  cases,  the  re- 
sults are  usually  only  those  which,  by  the  slight  improvement 
gained,  aid  the  child  in  its  proper  education  as  a  deaf  mute. 

It  is  necessary,  then,  when  medical  or  surgical  relief  cannot 
restore  the  child's  hearing,  to  advise  such  measures  as  may 
enable  the  child,  by  proper  education,  in  its  forlorn  condition, 
to  acquire  by  intelligent  training,  the  power  of  speech  in  the 
absence  of  its  hearing. 

We  have  now  in  all  large  cities,  homes  and  schools  which  are 
designed  to  meet  the  necessity  for  the  physical,  moral  and 
intellectual  training  of  those  children  who  are  both  deaf  and 
dumb.  The  good  results  obtained  from  this  educational  treat- 
ment of  the  diseased  conditions,  which  cause  complete  deafness 
in  childhood,  seem  wonderful  to  even  those  who  have  given  the 
matter  thought.  The  instructions  afforded  in  these  institutions,, 
which  enable  the  child  to  gain  or  acquire  the  power  of  speech, 
from  the  expression  and  motion  of  the  lips  or  the  mechanical 
vibration  of  the  larynx  of  the  teacher  when  felt  by  the  child,  is 
such  as  to  give  to  those  deaf  mutes,  which  have  good  intelli- 
gence and  normal  vocal  organs,  the  power  of  conversing  in  any 
language  which  has  thus  been  taught,  and  often  present  a 
general  knowledge  and  education  which  seems  incomprehen- 
sible to  those  who  hear. 

Much  may  be  accomplished  by  treatment,  in  the  way  of  the 
absorption  of  inflammatory  deposits  in  the  internal  ear,  or  the 
dissipation  of  the  effects  of  the  disease  which  has  destroyed  its 
functions  by  such  homeopathic  remedies  as  hepar  sulph.,  silicea, 
calc.  carb.,  ferrum  phos.,  and  the  employment  of  like  remedies, 
strychnia,  gelsemium,  and  the  salicylates,  which  may  have 
a  revivifying  and  stimulating  effect  upon  the  auditory  nerve. 
Such  adjuncts  as  electricity,  and  other  local  measures  which 
may  improve  the  condition  of  the  middle  ear  or  its  throat  por- 
tion, are  to  be  considered. 

When  a  child  has  lost  its  articulation  as  a  result  of  disease  of 
the  internal  or  middle  ear,  we  should  direct  the  attention  of  the 
parents  or  guardian  of  the  child  to  the  necessity  for  that  educa- 
tional treatment  of  the  child,  which  may  enable  it  to  acquire  a 
knowledge  and  education  not  otherwise  attainable,  and  which 
may  give  it  the  ability  to  hold  a  position  in  the  community 
in  which  it  resides,  oftentimes  higher  than  that  of  some  others 
with  normal  hearing  and  less  intellectual  development. 

The  education  of  the  deaf  and  dumb  child  should  be  begun 


AURAL  REMEDIES.  141 

as  soon  as  possible  after  its  deafness  has  been  determined. 
Every  effort  should  be  made  to  have  it  learn  to  articulate  and 
discourage  its  effort  to  communicate  by  signs. 

When  a  child  appears  stupid,  inattentive,  or  does  not  keep 
pace  with  its  associates  in  the  intellectual  race  at  kindergarten 
or  school,  humanity  demands  an  investigation  of  the  ears,  as 
well  as  the  eyes  of  the  child,  by  a  competent  medical  adviser, 
who  may  find  that  the  fault  is  not  in  lack  of  cerebral  develop- 
ment, but  loss  of  audition.  The  hearing  power  of  the  teacher 
is  frequently  less  than  it  should  be,  and  what  appears  to  be  only 
the  fault  of  the  child,  may  be  due  to  impaired  hearing  upon  the 
part  of  both  the  tutor  and  child,  or  want  of  judgment  upon 
the  part  of  the  teacher  when  the  child's  hearing  is  impaired. 
The  child  at  school  with  imperfect  sight  or  hearing,  too  often 
seems  to  have  assigned  to  it  the  desk  most  remote  from  the 
blackboard,  or  the  teacher's  platform.  The  teachers  of  to-day, 
however,  recognize  the  fact,  that  they  themselves  may  also 
have  faulty  eyes  and  ears  ;  and  when  cognizant  of  such  defects, 
are  more  charitable  to  the  children  under  their  educational  su- 
pervision. When  complete  deafness  is  present,  its  recognition 
is  usually  easy  for  the  teacher  ;  but  when  only  partial,  the  child 
suffers  from  non-appreciation  of  its  defective  hearing,  is  placed 
at  the  foot  of  the  class,  and  reprimanded  for  inattention,  or  said 
to  be  stupid.  To  one  who  is  brought  by  his  professional  rela- 
tion in  close  contact  with  these  children,  who  are  too  often  the 
innocent  sufferers  of  both  mental  and  physical  punishment,  be- 
cause of  their  defective  hearing,  it  seems  an  earlier  considera- 
tion of  the  possible  defect  should  be  given  in  all  cases,  where 
other  causes  which  may  occasion  them  are  absent,  and  an 
examination  by  an  aural  expert  be  advised. 

Aural  Remedies. — The  homeopathic  indications  of  the 
most  common  aural  remedies  are  grouped  together  here,  and 
have  been  taken  from  Prof.  H.  C.  Houghton's  work  on  Clinical 
Otology,  as  they  present  the  most  valuable  summary  extant. 

Aconitum. — In  acute  suppuration  of  the  middle  ear,  or  for 
acute  symptoms  arising  in  chronic  cases. 

Auruni  Met. — Is  indicated  in  suppurative  inflammation  of 
the  middle  ear  when  the  periosteum  of  the  temporal  bone  is 
affected.  The  subjective  symptoms,  so  far  as  the  ear  is  con- 
cerned, are  decidedly  negative ;  but  the  general  ones  make  the 
choice  between  this  remedy  and  fluoric  acid,  nitric  acid,  or 
^ilicea,  easy. 

Baryta  Muriatica. — Baryta  is  one  of  our  most  valuable  rem- 
edies, both  in  suppurative'  and  non-suppurative  inflammation 
of  the  middle  ear.     Hardness  of  hearing,  severe  buzzing  in  the 


142  THE  DISEASES  OF  CHILDREN. 

ears,  crackling  in  both  ears  when  swallowing,  a  reverberation  in 
the  ear  on  blowing  the  nose. 

Belladonna. — In  acute  inflammation  of  the  middle  ear,  or 
when  acute  symptoms  arise  in  chronic  disease. 

Calcarea  Carbonica  applies  to  the  same  class  of  patients  as 
in  general  diseases  —  the  fat,  rapidly  growing,  large-headed, 
soft-boned  children,  or  adults  who  in  youth  were  vigorous,  but 
now  fail  from  low  power  of  assimilation  ;  great  weakness,  sensi- 
tive to  cold,  damp  air.  The  pains  about  the  head  are  pressing 
or  pulsating,  often  semi-lateral ;  coldness  or  perspiration  of  the 
head ;  detonation  in  the  ears ;  meatus  filled  with  whitish^ 
fetid  pus  or  viscid  discharge. 

Capsicum. — For  chronic  suppuration.  The  pains  in  and 
around  the  ear  are  acute,  shooting,  pressing,  with  bursting 
headache.  On  the  mastoid,  behind  the  ear,  a  swelling  painful 
to  touch. 

Elaps  Corallinus. — Indicated  in  the  chronic  suppurative  form 
of  disease,  complicated  with  naso-pharyngeal  catarrh  ;  the  pos- 
terior wall  of  the  pharynx  covered  with  crusts  ;  external  meatus 
full  of  offensive  yellowish-green  discharge,  which  stains  the 
linen  green  ;  membrana  tympani  usually  perforated. 

Ferrum  Phos. — Schussler  claims  that  this  salt  controls  the 
beginning  of  disease.  "  Whilst  iron  restores  to  their  normal 
condition  the  blood-vessels,  enlarged  by  disease,  it  heals  the 
irritative  hyperemia,  which  is  the  cause  of  the  first  stage  of  all 
inflammations."  This  remedy  has  been  called  "  tissue  aconite." 
One  characteristic  may  guide  to  its  use — beating  in  the  ear 
and  head  ;  the  pulse  can  be  counted  in  the  ear,  one  patient 
remarked. 

Gelseniium. — While  this  remedy  may  be  more  frequently 
needed  in  acute  disease  of  the  middle  ear,  it  may  be  specially 
effective  in  mastoid  disease,  or  acute  necrosis,  complicating 
acute  suppuration. 

Graphites. — The  relation  of  this  remedy  to  the  nutrition  of 
the  skin  holds  good  in  dry  conditions  of  the  mucous  mem- 
brane; indeed,  we  may  infer  very  much  of  the  condition  of  the 
tympanum  from  study  of  the  dermoid  layer  of  the  external 
auditory  canal.  Hence,  the  condition  is  that  of  sclerosis  or 
proliferous  inflammation.  The  membrana  tympani  may  be 
opaque  and  thick,  or  transparent  and  very  thin,  adherent  to 
ossicula  or  promontory,  or  perhaps  mobile  ;  eustachian  tube 
dilatable,  but  hearing  not  improved  by  inflation.  There  is  one 
subjective  symptom  which  is  characteristic — "  hearing  improved 
in  a  noise." 

Hepar  Sulphuris  Calcarea. — In  the  suppurative  form ;  mem- 
brana tympani  perforated;   ulceration  angry;  discharge  small 


AURAL  REMEDIES.  143 

in  amount,  sour,  and  of  fetid  odor ;  the  tissue  very  sensitive, 
often  covered  with  white  shreds,  which  cHng  to  the  ulcer. 
Subjective  symptoms:  soreness  in  small  spots  about  the  ear; 
itching ;  patient  worse  at  night  and  by  cold  air. 

Hydrastis  Canadensis  stands  first  among  remedies  for  muco- 
purulent discharge  from  the  middle  ear.  In  purulent  inflam- 
mation of  the  middle  ear,  with  thick,  tenacious  discharge,  more 
mucus  than  pus,  this  remedy  is  invaluable. 

Iodine. — In  chronic,  non-suppurative  disease.  Curative  in 
atrophy  of  mucous  membrane,  probably  by  stimulating  glandu- 
lar elements  of  structure. 

Kali  Bichromicum. — In  chronic  suppuration ;  membrana  tym- 
pani  perforated ;  the  cicatrization  of  the  edges  of  the  perfora- 
tion complete ;  the  tissues  have  an  appearance  as  if  changed 
to  mucous  membrane,  and  the  secretion  is  often  more  mucus 
than  pus ;  the  discharge  yellow,  thick,  tenacious,  so  that  it 
may  be  drawn  through  the  perforation  in  strings.  The  sub- 
jective symptoms  are  lancinations,  sticking  sensations,  that 
the  patients  are  not  able  to  locate  with  any  degree  of  posi- 
tiveness. 

Kali  Muriaticum. — One  of  the  most  effective  remedies  we 
have  ever  used  for  chronic  catarrhal  inflammation  of  the  middle 
ear,  specially  of  the  form  designated  "  proliferous."  Subjec- 
tive symptoms,  a  stuffy  sensation  in  the  recent  cases,  subjective 
sounds,  and  deafness  are  very  marked.  The  objective  symp- 
toms are,  the  naso-pharyngeal  tonsil,  closed  eustachian  tube, 
retracted  membrana  tympani  and  atrophied  walls  of  the  ex- 
ternal meatus. 

Kali  Phosphoricum. — For  suppurative  disease,  specially 
chronic  form,  Schussler  says:  "Potassium  phosphate  cures  the 
following  diseased  conditions :  septic,  scorbutic  bleedings,  mor- 
tifications, encephaloid  cancer,  gangrenous  croup,  phagedenic 
chancre,  putrid-smelling  diarrhea,  adynamic  typhoid  condition, 
etc."  From  the  foregoing  indications,  we  are  led  to  use  it  in 
ulceration  of  the  membrana  tympani,  with  or  without  perfora- 
tion, in  suppuration  of  the  middle  ear,  the  pus  being  watery, 
dirty,  brownish,  very  fetid,  the  ulceration  angry,  bleeding 
easily,  and  showing  little  tendency  to  granulate,  or  secret  laud- 
able pus. 

Kali  Siilph. — For  catarrhal  disease  or  suppuration,  if  the 
discharge  be  muco-purulent  rather  than  purulent.  The  guid- 
ing symptom  is  the  color  of  the  secretion,  which  is  yellow,  sticky 
and  tenacious. 

Mercurius  Dulcis. — In  chronic  catarrhal  inflammation  of  the 
middle  ear.  The  objective  symptoms  are  those  of  this  form  of 
inflammation,— membrana  tympani  retracted,  thickened   and 


144  THE  DISEASES  OF  CHILDREN. 

immovable  by  inflation  ;  a  granular  or  hypertrophied  condition 
of  the  pharyngeal  mucous  membrane.  The  subjective  ones  are 
those  of  a  benumbed,  dull  feeling  between  the  throat  and  ear, 
a  pressure  in  the  ear  from  without. 

Mercurius  Solubilis. — Otitis  following  exanthemata,  and  in 
scrofulous  and  syphilitic  patients,  pain  in  ear,  extending  to 
face  and  teeth,  worse  by  the  heat  of  bed ;  excoriation  and  ul- 
ceration of  meatus ;  sensitive  to  cold  ;  abundant  secretion  of 
cerumen  or  flow  of  pus  and  blood ;  sweating  without  relief,  oc- 
curring from  cold,  when  there  are  hypertrophied  tonsils  or 
diseased  parotids  ;  pulsative  roaring  in  the  affected  part ;  ulcera- 
tion of  the  membrana  tympani,  which  bleeds  from  the  slightest 
touch ;  constant  cold  sensation  in  the  ears. 

Phosphorus  corresponds  to  a  dry  condition  of  the  tympanum. 
One  objective,  symptom,  deafness,  is  interesting  in  this  re- 
spect, that  the  failure  is  especially  for  the  human  voice ;  noises 
and  musical  tones  are  recognized  much  more  readily  than  the 
modulations  of  voice. 

Psorinum. — A  remedy  closely  allied  to  sulphur.  In  chronic 
suppuration,  where  the  symptoms  remain  unchanged  after  sul- 
phur, the  ulcers  scab  over  rapidly  ;  the  pus  very  fetid,  with  the 
ulceration  of  the  membrana  tympani ;  scabby  ulcers  on  the  ver- 
tex and  behind  the  ears.  Subjective  symptoms :  excessive 
itching  in  the  ears,  so  that  children  can  hardly  be  kept  from 
picking  or  boring  in  the  meatus. 

Pulsatilla. — For  acute  catarrhal  inflammation,  or  chronic 
suppuration,  when  the  discharge  is  a  bland  muco-purulent  secre- 
tion. Fever  without  thirst,  relief  of  pains  in  the  open  air,  and 
a  peevish,  changeable,  timid  disposition,  indicating  the  nervous 
depression,  are  guiding  symptoms. 

Silicia. — In  chronic  suppuration  ;  ulceration  in  cachectic  sub- 
jects, or  those  who  have  been  dosed  with  mercury ;  in  caries  or 
necrosis.  Objective  symptoms :  membrana  tympani  perfor- 
ated and  irregular ;  secretion  of  pus  scanty ;  ulcers  deep,  and 
covered  with  scabs  unless  frequently  cleansed.  More  repairs 
of  the  membrane  occur  under  the  use  of  this  remedy,  in  chronic 
diseases,  than  under  any  other  single  remedy. 

Sulphur. — The  indications  for  this  remedy  must  be  sought  in 
general  rather  than  in  special  objective  ones,  as  they  are  meager 
compared  with  the  last-mentioned  remedy  as  well  as  others. 
Itching  in  the  ears,  drawing  or  shooting  pains  in  the  ears ;  dis- 
charge of  pus,  stinking,  with  crusts. 

Tellurium. — Curative  in  chronic  suppuration,  when  the 
symptoms  correspond  to  the  following :  a  watery  fluid,  smell- 
ing like  fish-pickle,  which  excoriates  the  meatus  and  the  skin 
wherever  it  flows.      After  the   suppuration    has  ceased,  the 


RELATIVE  DISEASES  OF  THE  EAR.  I45 

membrane  has  been  found  cicatrized  and  corrugated,  but  not 
thickened. 

Thuya  Oc. — The  special  indication  for  this  remedy  is  the  dis- 
charge "smelling  like  putrid  meat."  Clinically  it  has  cured 
granulations  in  the  meatus  similar  to  condylomata. 

Diseases  of  the  Ear  in  Their  Relation  to  the  Gen- 
eral Economy  of  the  Child.— Affections  of  the  ear  as  well 
as  those  of  the  eye  have  a  causative  value  in  the  production 
of  diseases  of  other  portions  of  the  child's  anatomy.  While 
the  possible  compHcations  which  may  arise  and  affect  other 
parts  of  the  child's  system  have  been  already  mentioned  in 
the  discussion  of  the  direct  inflammatory  affections  of  the  ear, 
it  may  be  well  to  recapitulate  here  the  general  systemic  affec- 
tions, which  may  accompany  or  follow  diseases  of  the  ear. 

When  the  infant  in  its  distress,  presents  objective  symptoms 
of  suffering  sufficient,  in  the  judgment  of  its  attendant,  to  call 
a  physician  for  relief,  it  may  be  difficult  for  him  to  formulate 
an  opinion  at  once  as  to  the  exact  lesion  which  may  be  present. 
It  should  be  considered  before  a  diagnosis  or  prognosis  is  made, 
that  while  the  symptoms  may  be  those  of  meningitis,  cerebro- 
spinal meningitis,  capillary  bronchitis,  pneumonia,  cerebral  irri- 
tation  with  convulsions,  that  an  affection  of  the  ear  may  be 
the  cause  of  the  symptoms  which  may  lead  to  an  erroneous 
diagnosis. 

Foreign  bodies  in  the  ear  may  occasion,  by  irritation  of  the 
walls  of  the  canal,  a  reflex  through  the  third  branch  of  the  fifth 
and  pneumogastric  nerves,  which  may  result  in  development 
of  what  appears  to  be  true  epileptoid  convulsions,  or,  perhaps, 
even  a  paralysis,  or  paresis  of  parts  of  the  same  side  of  the 
body  as  that  of  the  ear  which  contains  the  foreign  substance. 
It  should  also  be  mentioned  that  similar  foreign  bodies  may  re- 
main in  the  auditory  canal  for  an  indefinite  period,  without  ex- 
citing any  such  reflex  disturbances  in  another  child,  owing  to  a 
less  abnormal  development  of  the  nerves  supplying  the  audi- 
tory meatus,  or  the  absence  of  a  hyper-sensitive  condition  of 
the  child's  nervous  system. 

There  is  a  form  of  epilepsy  which  has  its  origin  in  otitis  me- 
dia, usually  of  the  chronic  suppurative  type,  where  the  attacks 
are  excited  by  inflammatory  thickening,  or  from  irritation  of 
the  middle  or  internal  ear,  resulting  from  pressure  due  to  in- 
flammation or  from  nerve  irritation  arising  during  the  destruc- 
tion of  the  parts.  It  is  more  frequently  found  associated  with 
caries  and  necrosis  of  the  internal  ear,  and  of  the  temporal  bone. 
The  mastoid,  when  diseased,  also  holds  a  causative  relation  oc- 
casionally. In  all  cases  of  epilepsy,  where  there  is  a  history  of 
D.  C— 10 


146  THE  DISEASES  OF  CHILDREN. 

aural  disease,  or  where  aural  symptoms  are  present,  it  is  well  to 
examine  into  the  condition  of  the  ear. 

Where  there  is  a  more  or  less  constant  discharge  from  one  or 
both  ears  of  the  child,  which  from  neglect,  or  want  of  proper 
treatment,  or  even  when  the  best  available  treatment  has  not 
caused  its  cessation,  the  child  then  exists  with  a  condition  which 
menaces  its  life  at  all  times,  and  which  may  at  any  time  on  the 
accession  of  an  increased  inflammation  due  to  cold,  or  the  ex- 
tension of  the  ulcerative  inflammation  of  the  mucous  mem- 
brane, and  periosteum  of  the  middle  ear,  result  in  dangerous  or 
fatal  complications,  such  as  meningitis  of  the  base  of  the  brain 
of  the  infant ;  that  of  the  convexity  in  older  children,  abscess 
of  the  brain,  phlebitis,  thrombosis  of  the  sinuses,  paralysis  of 
the  face,  hemiplegia,  mastoid  inflammation,  caries  and  necrosis 
of  the  temporal  bones,  epilepsy,  chorea,  stupidity,  idiocy,  per- 
sistent cough,  nausea,  or  vomiting,  or  death. 

Should  the  pedologist  doubt,  from  the  list  presented  of  dis- 
eases of  the  ear,  with  their  possible  complications,  or  fatal  cul- 
mination, which  are  by  the  aurist  to  be  considered  as  possible 
causes  before  a  diagnosis  in  obscure  cases  is  given,  even  where 
no  ear  affection  has  been  noticed  or  considered  likely  to  have 
any  bearing  upon  the  condition  presented,  he  will  find  their 
importance  unquestioned,  after  the  observation  and  experience 
which  comes  from  an  extended  aural  practice. 

General  Diseases  of  the  Child  in  Their  Effect  upon 
THE  Ears. — In  the  discussion  of  the  various  diseases  of  the 
ear,  those  which  produce  more  directly  an  involvement  of  the 
organ  of  hearing,  such  as  dentition,  the  exanthemata,  diph- 
theria, typhoid  fever,  pneumonia,  bronchitis,  catarrhal  condi- 
tions, and  other  diseases  of  the  nose  and  pharynx,  have  already 
been  partly  considered,  and  as  they  bear  by  far  the  greater 
causative  relation  to  ear  diseases,  they  demand  still  further 
attention.  The  fact  should  be  noted  that  affections  of  the 
auricle  and  the  external  auditory  canal  result  from  eczema, 
or  other  affections  of  the  skin  of  the  head  or  face,  by  an  exten- 
sion of  the  disease  through  continuity. 

In  all  cases  where  an  ear  affection  is  noticed,  the  careful 
consideration  of  the  general  condition  of  the  infant  or  child 
is  of  the  utmost  importance  in  the  effort  to  cure  the  local 
affection. 

Cerebro- Anemia  or  Hyperemia  may  produce  more  or  less 
giddiness,  or  even  marked  vertigo,  due  to  circulatory  disturb- 
ances in  the  labyrinth  with  or  without  impairment  of  hearing, 
and  is  usually  associated  with  disturbance  or  loss  of  vision 
from  the  same  cause.     When    hyperemia  is  present  there  is 


GENERAL  DISEASES  AND  THEIR  EFFECT.        147 

usually  vertigo,  with  the  complaint  in  older  children  of  noises 
in  the  ear,  with  or  without  visual  destructions.  Anemic 
conditions  more  often  cause  transient  loss  of  hearing  with 
faintness. 

Tumors  of  the  Brain,  and  hydrocephalus,  while  more  common 
causes  of  eye  changes  and  loss  of  vision,  produce  deafness  by 
affecting  the  integrity  of  the  tissues  of  the  internal  ear.  A 
descending  neuritis  of  the  auditory  nerve  or  serous  inflamma- 
tion and  destruction  in  cerebro-spinal  meningitis,  particularly 
of  the  epidemic  form,  while  frequently  affecting  both  the  eyes 
and  ears  is  more  likely  to  impress  the  ear  early  in  the  attack, 
usually  during  the  first  few  days,  and  the  serous  or  suppura- 
tive inflammation  set  up  in  the  internal  ear  is  followed  by  a 
more  or  less  complete  deafness.  Cerebro-spinal  fever,  in  con- 
junction with  meningitis,  the  latter  taking  the  lesser  promi- 
nence, are  the  most  frequent  causes  of  destruction  of  the  func- 
tion of  the  internal  ear,  and  present  the  most  common  cause 
of  deaf-mutism  as  shown  by  the  census  reports.  The  destruc- 
tion of  the  nerve  which  is  exhibited  in  those  cases  is  due  to  an 
extension  of  the  inflammation  from  the  brain. 

Meningitis,  next  to  cerebro-spinal  meningitis  is  the  most  fre- 
quent cause  of  destruction  of  the  hearing  function  in  infancy 
and  childhood,  and  the  loss  may  be  due  to  the  complication  of 
both  middle  and  internal  ears. 

Nephritis  in  childhood  is  rarely  cause  of  an  aural  affection, 
except  when  the  nephritic  condition  is  the  cause  of  lowered 
vitality,  then  a  circumscribed  inflammation  of  the  external 
auditory  canal  may  occur,  as  in  the  "  cat  boils  "  or  small  ab- 
scesses of  the  canal,  which  appear  at  any  age  as  the  result  of 
malnutrition  and  are  often  indications  of  the  general  con- 
dition. 

Typhoid  Fever,  bronchitis  and  pneumonia  should  be  borne  in 
mind  as  causes  of  aural  complications  which  are  not  uncom- 
mon and  that  deafness,  or  insomnia,  or  coma  may  arise  from 
ear  complications.  In  the  grippe  influenzas  of  the  last  three 
years  the  ears  have  suffered  more  often  from  mastoid  compli- 
cations than  in  the  common  influenzas,  which  are  too  often 
the  cause  of  uncomplicated  otitis  media.  During  childhood, 
which  in  our  climate  is  usually  limited  to  the  first  fourteen  or 
fifteen  years  of  life,  typhoid  fever  presents  affections  of  the 
middle  ear  due  mainly  to  the  extension  by  continuity  in  cases 
where  the  catarrhal  symptoms  are  prominent.  The  mucous 
membrane  of  the  pharynx  and  naso-pharynx  being  commonly 
subject  to  inflammations  in  all  fevers,  whether  typhoid,  typhus, 
remittent  or  other  fevers,  the  possible  ear  complications  in  all 
febrile  conditions  are  to  be  thought  of.     While  in   a  general 


148  THE  D/S EASES  OF  CHILDREN. 

sense  the  cases  may  not  be  common  to  the  general  practitioner, 
the  aurist  has  in  his  practice  to  examine,  treat  and  relieve 
many  cases  of  deafness  which  are  complications  of  these  dis- 
eases. 

Intestinal  Diseases. — Affections  of  the  alimentary  tract  have 
little  connection  in  a  causative  way  with  aural  diseases,  except 
in  as  far  as  they  affect  the  nutrition  of  the  tissues  of  the  ear, 
and  by  aggravating  a  pre-existing  naso-pharyngeal  condition  of 
catarrh  cause  a  middle-ear  catarrh,  acute  or  chronic,  or  a  sup- 
purative inflammation  with  all  its  possible  results,  which 
involve  the  hearing  and  life  of  the  child. 

Dentition. — During  the  eruption  of  the  teeth  the  infant 
often  suffers  from  congestion  of  the  auditory  canal  and  of 
the  drum  cavity  or  the  eustachian  tube,  which  is  accompanied 
by  severe  pain  in  the  ear,  the  cause  of  the  crying  of  the  child 
being  referred  to  the  swollen  gums  which  are  less  rarely  the 
seat  of,  although  the  indirect  cause  of,  the  pain.  The  relief 
obtained  in  such  cases  from  the  application  of  dry  heat  to  the 
ear  enables  us  to  determine  the  fact  that  an  ear  complication 
due  to  dental  irritation  is  present.  When  the  irritation  is  pro- 
longed, a  slight  discharge  of  pinkish  serum  from  the  engorged 
blood-vessels  appears  upon  the  pillow,  or  in  more  severe  cases, 
the  external  auditory  canal  fills  with  pus  or  muco-pus  from 
middle-ear  suppuration  upon  the  rupture  of  the  drum-head. 
In  all  cases  attention  should  be  directed  to  the  gums,  and 
relief  obtained  by  lancing  them  whenever  it  may  be  deemed 
advisable. 

Syphilis. — In  infancy,  childhood  and  adult  life  the  affections 
of  the  ear  from  primary  syphilis  are  extremely  rare ;  an 
occasional  case  of  chancre  of  the  auricle  has  been  reported.  In 
the  infant  the  syphilitic  infection  of  it  may  have  been  pre-natal 
and  the  expression  of  the  disease  upon  the  ears  that  of  the 
tertiary  stage. 

During  childhood  a  sudden  and  complete  deafness  may 
occur  as  the  result  of  the  inherited  dyscrasia,  which  affects  the 
internal  ear,  or  in  other  cases  the  hearing  be  slowly  lost,  owing 
to  more  gradual  disease  changes  in  the  middle  or  internal  ear. 

Scarlatina. — Of  the  exanthemata  none  cause  such  frequent 
implication  of  the  middle  ear  with  destructive  suppuration, 
acute  and  chronic,  loss  of  hearing  and  all  the  complications  and 
sequela  which  may  result,  than  scarlet  fever.  Next  to  men- 
ingitis and  cerebro-spinal  meningitis,  this  disease  furnishes  the 
largest  number  of  cases  of  deaf  mutes ;  according  to  the  last 
census  report  25  per  cent,  were  caused  by  scarlet  fever. 

Rubeola. — Measles  immediately  follow  scarlatina  in  order  of 
frequency  as  a  cause  of  aural  destruction.     The  implication  of 


GENERAL  DISEASES  AND  THEIR  EFFECT.         149 

the  throat  and  naso-pharnyx  in  both  these  exanthems,  make 
the  extension  of  the  disease  to  the  ear  very  easy,  and  the  in- 
flammation thus  produced  is  followed  by  destruction  of  the 
essential  portions  of  the  hearing  apparatus,  and  leaves  condi- 
tions of  chronic  ulceration,  adhesions  in  the  chain  of  ossicles, 
and  progressive  deafness. 

Diphtheria. — Statistics  show  that  diphtheria  is  a  frequent 
cause  of  deafness,  and  the  direct  cause  in  cases  when  it  is  asso- 
ciated with  scarlet  fever  or  when  the  membrane  invades  the 
upper  pharynx.  The  malignancy  of  the  disease  is  such  that 
when  the  child  becomes  deaf  from  the  invasion  of  the  middle 
ear,  if  it  survives  the  diphtheritic  attack,  it  is  likely  to  become 
permanently  deaf,  owing  to  the  destruction  in  the  ear  and  the 
subsequent  changes  in  it  which  follow. 

Variola. — In  small-pox,  the  impression  made  upon  the  ear 
is  less  marked  than  that  upon  the  eye,  as  the  pustules  are 
rarely  if  ever  found  in  the  ear.  Occasionally  there  is  during 
the  course  of  the  disease,  a  middle-ear  suppuration,  which, 
however,  should  not  be  considered  the  result  of  direct  infection. 

Pertussis. — Whooping  cough  not  infrequently  produces  ear 
complications,  as  hemorrhages  in  the  drum  cavity,  or  rupture 
of  the  drum-head  which  may  occur  during  prolonged  paroxysms 
of  cough.  A  middle-ear  catarrh  or  suppuration  is  not  uncom- 
mon, either  during  the  attack  or  following  it. 

Parotiditis. — Mumps  rarely  cause  an  implication  of  the  ear 
during  the  stage  of  swelling  of  the  gland,  but  often  after  the 
attack  has  passed,  inflammations  of  the  middle  ear  may  follow. 
The  internal  ear  may  also  suffer  loss  of  function  as  a  result  of 
the  metastasis  of  the  disease. 

Typhoid  Fever. — The  mucous  membrane  of  the  nose  and 
throat  are  commonly  subject  to  inflammation  during  typhoid, 
typhus,  remittent  or  other  fevers ;  for  this  reason  middle-ear 
complications  are  frequently  presented.  Occasionally  one  or 
both  labyrinths  are  affected  by  cell  infiltration  during  the 
course  of  the  fever  which  may  result  in  temporary  or  permanent 
deafness. 

Diseases  of  the  Heart  are  scarcely  ever  known  to  produce 
any  direct  effect  upon  the  ears  of  children. 

Diseases  of  the  Central  Nervous  System  cause  loss  of  hearing 
more  or  less  complete  from  affections  of  the  internal  ear.  In 
the  brain,  changes  in  the  cortex  present  such  unique  phenom- 
enon as  deafness  for  certain  words,  or  '*word  deafness." 

Diseases  of  the  Sexual  System.— Those  changes  in  the  general 
system  occurring  at  puberty,  as  a  rule  produce  less  affection  of 
the  auditory  than  those  of  the  visual  organs.  It  is  rarely  that 
we  find  at  puberty  an  appreciable  effect  of  the  change  in  the 


150  THE  DISEASES  OF  CHILDREN. 

sexual  system  upon  the  ear ;  even  when  noticed,  usually  caus- 
ing only  an  aggravation  of  a  tendency  to  ear  disease  which  had 
previously  existed. 

Injuries  of  the  Ear. — The  auricle  and  outer  portion  of  the 
canal  are  rarely  the  seat  of  direct  injury,  except  those  which 
result  from  the  attempts  to  remove  foreign  bodies  from  the 
ear.  At  times  an  insect  may  find  its  way  into  the  infant's  ear 
while  sleeping  upon  the  ground,  or  even  in  its  crib.  The  diag- 
nosis of  the  cause  of  the  infant's  discomfort  cannot  always  be 
readily  arrived  at,  but  in  the  absence  of  other  afTections  which 
account  for  it,  a  glance  into  its  ear  may  reveal  the  presence  of 
an  insect ;  then  a  few  drops  of  water,  oil,  or  any  bland  fluid  in- 
stilled into  the  ear,  will  at  once  quiet  the  child  by  drowning 
the  insect,  which  soon  appears  in  the  fluid  at  the  outer  portion 
of  the  canal. 

Occasionally  we  are  called  upon  to  treat  a  punctured  wound 
which  follows  the  introduction  of  some  sharp-pointed  stick  or 
instrument. 

In  infancy,  owing  to  the  more  horizontal  position  of  the  drum- 
head, it  escapes  injury  unless  much  force  is  exerted.  Injuries 
of  the  deeper  portion  of  the  ear  are  apt  to  be  followed  by  men- 
ingeal inflammation  arising  from  the  trauma. 

During  childhood,  foreign  bodies  of  all  kinds  are  frequently 
put  into  the  ear  by  the  child  or  its  playmates.  The  size  is  al- 
ways less  than  the  caliber  of  the  meatus  and  this  fact  should 
always  be  kept  in  mind.  The  child  never  pushes  it  so  far  in 
that  with  intelligent  care,  it  cannot  be  readily  removed  ;  in  the 
majority  of  cases,  when  foreign  substances  are  in  the  canals, 
changing  the  position  of  the  head,  by  placing  the  child  on  a 
table  with  the  head  extending  beyond  it  and  the  ear  containing 
the  foreign  body  directed  towards  the  floor,  a  slight  pulling 
downward  of  the  ear,  thus  straightening  the  canal,  results  in  the 
falling  of  the  body  by  the  force  of  gravity  to  the  floor.  If  this 
fails,  then  no  effort  should  be  made  to  remove  it,  without  first 
having  ascertained  its  exact  nature  and  position  under  a  full 
illumination.  Even  then  it  is  better  to  use  the  syringe  and 
water  than  to  attempt  its  instrumental  removal  except  in  the 
most  skillful  hands.  In  the  majority  of  cases,  where  foreign 
bodies  have  been  placed  in  the  ear,  the  danger  is  always  greater 
of  injury  to  the  ear  from  the  misguided  efforts  at  its  removal 
than  from  the  foreign  body  itself.  Ordinarily,  an  object  put  in 
the  ear,  unless  pressing  upon  the  drum-head,  which  occurrence 
is  very  rare,  except  as  the  result  of  an  attempt  to  remove  it, 
may  remain  there  for  years  without  other  disturbance  than  a 
partial  or  complete  loss  of  the  hearing  in   the  stopped  ear. 


INJUR lES  OF  THE  EAR.  151 

Pebble-stones,  seeds  of  all  kinds,  sufficiently  small  to  pass  into 
the  canal,  deciduous  teeth,  shoe-buttons,  cork,  pieces  of  cloth, 
wads  of  cotton,  and  various  other  substances  have,  in  the  writ- 
er's experience,  been  removed  from  the  ears,  after  having  re- 
mained there  for  weeks,  months  and  many  years  without  occa- 
sioning any  disturbance  except  that  of  defective  hearing.  It 
has  been  the  good  fortune  of  the  aurist  to  relieve  what  has 
appeared  to  be  serious  neuroses;  but  when,  in  the  absence  of  a 
satisfactory  explanation,  their  cause  has  led  to  the  examination 
of  the  ear  where  deafness  of  one  ear  had  been  noticed  and  the 
removal  of  a  foreign  substance,  which,  pressing  upon  the  walls 
of  the  canal  occasioned  the  reflex  symptoms,  removed  all  dif- 
ficulty. 

Tumors  of  the  ear  or  malignant  disease  are  so  rare  in  child- 
hood that  they  need  no  discussion  here. 


PARX     III. 

DISEASES  OF  THE  DIGESTIVE  ORGANS. 


CHAPTER  I. 
GENERAL  CONSIDERATIONS. 

Diseases  of  the  digestive  apparatus  are  exceedingly  com- 
mon in  infancy  and  childhood,  and  only  the  greatest  care  in 
the  management  of  the  food,  the  clothing  and  the  hygiene 
of  the  nursery  can  avoid  them.  Even  under  the  most  favora- 
ble circumstances  and  when  every  care  has  been  exercised, 
vicissitudes  of  climate,  atmospheric  changes,  impurities  in 
food  which  have  eluded  all  vigilance  and  other  factors  which 
the  greatest  foresight  cannot  eradicate,  render  disturbances 
of  this  part  of  the  organism  among  the  most  frequent  that 
the  physician  has  to  deal  with.  Whoever  has  read  the  pre- 
ceding pages  must  have  recognized  the  difficulties  encountered 
by  one  endeavoring  to  meet  the  nutritive  wants  of  a  young 
infant,  whose  powers  of  assimilation  are  at  best  but  feeble  and 
who  may  possess  peculiarities  or  idiosyncracies  which  experi- 
ment and  repeated  trials  alone  can  render  intelligible.  The 
diseases  and  disturbances  of  function  which  we  are  about  to 
consider  are  usually  readily  recognized  and  generally  at  their 
beginning  easily  remedied  by  intelligent  treatment.  They  can- 
not, however,  be  neglected ;  for,  trivial  as  they  may  seem  in 
their  incipiency,  they  are  liable  to  become  chronic  and  obstinate 
or  even  fatal.  A  timely  recognition  of  the  malady,  a  true  un- 
derstanding  of  its  pathology,  and  a  judicious  selection  of  reme- 
dies are  imperative. 

It  will  be  found,  especially  in  hand-fed  infants,  that  a  change 
of  diet  is  frequently  an  essential  part  of  the  treatment.  In 
cases  where  vomiting  or  diarrhea  is  a  prominent  symptom,  it 
will  be  advisable  for  a  day  or  two  to  suspend  cow's  milk  either 
partly  or  wholly,  and  to  substitute  cream  therefor.  In  obsti- 
nate cases  of  this  kind,  in  which  the  milk  is  thrown  up  curdled, 
or  passed  undigested  in  the  stools,  raw-meat  juice,  spoken  of  in 
another  chapter,  or  bread  jelly  should  not  be  forgotten.  The 
(152) 


SIMPLE  OR  CATARRHAL  STOMATITIS.  153 

gelatin  food  of  Dr.  Meigs  is  another  food  that  meets  the  special 
wants  of  some  of  these  cases. 

Oftentimes  a  sHght  change  in  the  customary  aliment  is 
sufficient  to  set  matters  to  rights ;  but  often,  again,  the  physi- 
cian will  be  sorely  puzzled  to  find  the  exact  food  that  will  fit 
the  case.  Nothing  but  watchful  and  persistent  care  will  insure 
success,  and  in  the  matter  of  remedies  the  closest  study  of  both 
symptoms  and  drugs  will  be  necessary. 

It  should  be  clearly  borne  in  mind  that  vomiting  in  infancy 
does  not  always  have  the  significance  that  it  carries  with  it  in 
adult  life.  Indeed,  vomiting  or  regurgitation  of  food  in  infancy 
may  be  simply  due  to  too  frequent  nursing  or  overfeeding  and 
may  have  no  pathological  significance  whatever.  It  occurs 
without  nausea  and  without  effort.  The  size  of  the  stomach,  as 
we  have  already  pointed  out  in  our  introductory  chapter,  is  rel- 
atively small — holding  at  the  age  of  two  months  only  about 
four  ounces,  and  at  twelve  months  about  ten  ounces — and  if 
this  capacity  for  food  be  exceeded,  as  it  often  is  by  a  healthy, 
vigorous  child,  the  vomiting  is  simply  the  overflow  which  is 
over  and  above  the  stomach's  needs.  The  position  of  the 
stomach,  moreover,  is  nearly  vertical  and  the  absence  of  the 
gastric  fundus  makes  vomiting  under  these  circumstances  a 
matter  of  great  ease.  The  milk  thus  ejected  is  unchanged,  or 
if  it  has  been  retained  for  some  moments  the  casein  may  be 
somewhat  coagulated.  In  either  event  there  is  little  harm  from 
its  being  thrown  up  ;  in  fact,  it  is  a  salutary  phenomenon,  for 
this  excess  of  food,  if  retained,  would  undergo  fermentation  and 
give  rise  to  irritation  either  of  stomach  or  bowels. 

Vomiting,  however,  when  attended  by  emaciation  or  loss  of 
vivacity,  or  if  frequently  repeated  when  there  has  been  no 
excess  of  feeding,  should  always  arrest  attention  and  its  cause 
be  ascertained.  It  may  be  the  first  symptom  of  gastric  irrita- 
tion or  of  incipient  meningitis. 

STOMATITIS. 

There  are  several  varieties  of  inflammation  of  the  mouth, 
which  are  very  common  among  infants  and  children,  the  mild- 
est of  which  is  known  as, 

Simple  or  Catarrhal  Stomatitis.  —  This  form  is  most 
commonly  met  with  in  hand-fed  babies,  before  the  completion 
of  first  dentition,  and  indeed  is  most  frequent  under  the  age  of 
one  year,  and  hence  is  often  described  by  the  laity  as  "  nursing 
sore  mouth."  It  may  sometimes  be  found  in  infants  at  the 
breast,  who  are,  to  all  appearances,  in  otherwise  good  health. 


154  THE  DISEASES  OF  CHILDREN. 

More  often,  however,  it  will  be  found  that  the  inflammation  of 
the  mouth  is  but  the  visible  symptom  of  a  derangement  that 
extends  to  the  stomach,  if  it  does  not  originate  there.  It  is 
frequently  encountered  in  the  course  of  any  of  the  constitu- 
tional diseases,  and  usually  accompanies  or  follows  the  eruptive 
fevers,  and  is  a  part  of  them.  Anything  which  lowers  the  tone 
of  health  may  lead  up  to  it,  while  teething  is  a  very  common 
cause.  In  these  cases,  the  gum  over  the  advancing  tooth  first 
becomes  inflamed,  and  from  this  as  a  starting-point  the  inflam- 
mation may  extend  over  a  portion  or  the  whole  of  the  buccal 
surface.  When  due  to  teething,  the  inflammation  is,  as  a  rule, 
partial  rather  than  general. 

Symptoms. — Inflammation  of  the  mouth,  from  whatever  cause, 
is  indicated  by  increased  redness,  and  more  or  less  thickening 
of  the  mucous  membrane,  and  by  increased  functional  activity 
of  the  mucous  follicles.  There  is  more  or  less  augmentation  of 
the  heat  of  the  mouth,  and  pain  is  experienced  when  the  in- 
flamed parts  are  touched.  In  some  cases  the  gums  become 
swollen  and  spongy,  and  bleed  easily  if  rubbed  or  pressed  upon. 
The  soreness  in  these  cases  is  the  most  prominent  symptom 
and  is  sometimes  so  great  as  to  materially  interfere  with  suction. 

The  tongue  is  generally  coated  with  a  light  fur  and  the  sali- 
vary secretion  is  more  or  less  increased — sometimes  so  much  so 
as  to  cause  dribbling  from  the  mouth.  Bleeding  from  the  gums 
is  not  uncommon  in  these  cases;  but  except  in  poor  and  neg- 
lected families  is  rarely  allowed  to  reach  such  a  stage.  The  in- 
fant is  restless  and  fretful,  and  apt  to  cry  whenever  it  attempts 
to  nurse,  from  the  pain  experienced  in  closing  on  the  nipple. 
There  is  little  or  no  general  fever ;  and,  except  in  cachectic  in- 
fants, or  those  suffering  from  some  grave  co-existing  disease,  is 
not  at  all  of  a  serious  nature.  It  usually  yields  readily  to  the 
simplest  treatment ;  but  in  some  instances,  if  neglected,  it  may 
terminate  in  one  of  the  more  severe  forms,  such  as  the  ulcerous 
or  aphthous. 

Treatment. — The  first  duty  of  the  physician  is  to  ascertain, 
if  possible,  the  cause  of  the  stomatitis  and  to  remove  or  cor- 
rect it.  Bathing  the  mouth  with  a  soft  linen  rag  wet  in  cold 
water  should  often  be  resorted  to,  as  it  cools  the  mouth  and 
constringes  the  relaxed  and  swollen  tissues.  If  the  gums  are 
swollen  from  teething,  it  is  quite  proper  to  lance  or  scarify  them, 
as  directed  in  the  chapter  on  teething.  Borax  is  a  very  useful 
local  remedy,  either  with  honey;  or  glycerine  and  water  in  the 
proportions  of  one  part  borax  to  three  of  honey  ;  or  a  drachm 
of  borax  to  an  ounce  of  glycerine  and  water.  A  weak  solution 
of  alum  is  also  useful.  One  of  these  preparations  frequently 
applied,  with  greater  attention  to  washing  the  mouth  and  gums 


UL  CER  OUS  S  TOM  A  TITIS.     ■  155 

after  each  feeding,  is  usually  all  that  is  necessary.  The  disease 
is  so  slight  in  this  simple  form  that  no  remedies  internally  ad- 
ministered are  necessary. 

Ulcerous  Stomatitis. — Sometimes  a  simple  stomatitis, 
instead  of  going  on  to  recovery,  quickly  eventuates  in  an  ulcer- 
ous condition  of  greater  or  less  extent. 

This  ulcerous  condition,  however,  when  present  is  always 
grafted  on,  or  succeeds  to,  the  simple  form  of  stomatitis.  The 
ulcers  commence  as  small  white  or  yellow  points  and  consist 
of  plastic  exudation  under  the  epithelium.  This  exudation 
produces  a  slight  elevation  or  prominence  of  the  mucous  mem- 
brane and  causes  an  ulceration  of  it.  The  inflammation  usually 
begins  upon  the  gums  and  extends  along  and  upon  the  buccal 
surface.  Some  of  these  white  points  unite  and  thus  enlarge 
the  affected  area.  This  extension  is  irregular,  and  in  some 
cases  forms  large  patches  of  ulceration.  There  is  no  uniform- 
ity as  regards  the  size  or  shape  of  the  ulcers.  In  the  folds  of 
the  buccal  membrane  they  are  apt  to  be  elongated,  while  in 
other  situations  they  may  be  round  or  oval.  As  disease  pro- 
gresses, fresh  ulcerations  appear,  until  in  some  cases  a  good  por- 
tion of  the  mucous  membrane  of  the  mouth  may  become  in- 
volved. It  is  no  unusual  thing  to  find  simple  inflammation  in 
one  portion  of  the  mouth  and  this  ulcerous  form  in  another. 
If  the  disease  is  severe,  there  is  considerable  swelling  about  the 
margins  of  the  ulcers  and  the  breath  is  sometimes  very  fetid. 
As  soon  as  improvement  begins  the  swelling  subsides,  the  ulcer- 
ous surface  becomes  more  clear  and  presents  a  granular  ap- 
pearance. After  a  time  the  mucous  membrane  is  reproduced, 
but  the  new  membrane  for  a  considerable  period  remains  of  a 
darker  hue  than  the  adjacent  surface.  Recurrence  of  attack 
is  very  common.  Such  cases  of  the  disease  are  rare  in  private 
practice,  but  in  hospitals  it  prevails  extensively  and  apparently 
in  epidemics. 

Causes. — Acidity  of  the  stomach  is  a  prime  cause  in  most 
cases.  Personal  uncleanliness,  poor  food,  damp  and  un- 
wholesome apartments — anything,  indeed,  which  reduces  the 
system  and  produces  a  cachectic  state  conduces  to  its  develop- 
ment. It  frequently  follows  the  essential  fevers  and  intestinal 
inflammations,  and  in  the  entero-colitis  of  infants  it  is  apt  to 
form  a  protracted  and  obstinate  complication.  Its  prevalence 
in  the  wards  of  a  hospital,  where  several  cases  occur  together 
or  consecutively,  has  been  thought  by  some  to  indicate  its 
contagiousness.  But  its  contagious  character  is  by  no  means 
established.  In  private  practice  it  exhibits  no  such  tendency, 
and  it  is  quite  as  reasonable  to  suppose  that,  in  multiple  cases, 


156  THE  DISEASES  OF  CHILDREN. 

there  is  a  common  exposure  to  the  same  malign  influences, 
just  as  a  whole  household  may  be  exposed  to  malaria  and  be 
seized  with  intermittent  fever.  We  have  already  spoken  of 
dentition  as  a  frequent  cause  of  simple  stomatitis,  and  the 
ulcerous  form  is  the  same  thing,  carried  a  step  further,  viz.,  to 
the  stage  of  ulceration. 

Symptoms. — The  symptoms  in  ulcerative  stomatitis  are  more 
severe  than  in  the  simple  form.  There  is  more  fever,  more 
fretfulness,  more  salivation  and  increased  tenderness  of  the 
parts  affected.  Drinks,  unless  lukewarm  and  very  bland,  are 
taken  only  with  pain  and  difficulty.  Both  heat  and  cold  are  in- 
tolerable. If  the  ulceration  is  on  the  gums  or  lips,  the  infant 
nurses  with  reluctance  and  cries  with  pain  when  the  attempt  is 
made.  It  should  be  stated,  however,  that  this  form  of  the  dis- 
ease is  not  so  common  among  infants  as  among  children.  Oc- 
casionally, though  rarely,  the  submaxillary  glands  are  tumefied, 
hard  and  tender.  The  breath  is  always  more  or  less  affected, 
and  in  some  cases  is  exceedingly  offensive. 

Prognosis. — The  prognosis  is  always  favorable,  unless  the 
patient  is  in  a  decidedly  cachectic  condition,  or  a  serious  co- 
existing disease  be  present.  Under  these  circumstances  it  may 
be  protracted.  When  the  ulcers  are  small  and  the  inflamma- 
tion of  limited  extent,  the  course  of  the  disease  is  shorter  and 
more  easily  managed  than  when  the  ulcers  are  large  and  the 
inflammation  more  extensive. 

Treatment.' — In  the  ulcerous,  as  in  the  simple  variety,  much 
relief  is  experienced  by  the  use  of  various  soothing  applications, 
applied  locally.  If  the  child  is  old  enough  to  use  a  mouth 
wash,  a  very  good  one  is  permanganate  of  potash,  one  grain  to 
the  ounce  of  water.  Another  wash  is  highly  recommended, 
viz.:  hydrastis,  which  may  be  used,  one-half  diluted  with 
water.  For  young  infants,  who  cannot,  of  course,  gargle  their 
mouths,  there  is  no  better  application  than  the  borax  and 
honey,  spoken  of  in  the  last  section,  applied  with  a  camel's-hair 
pencil  over  the  affected  area.  This  should  be  done  several 
times  daily.  As  for  internal  remedies,  the  fact  that  calomel, 
when  given  to  children,  produces  a  disease  of  the  mucous 
membrane  of  the  mouth  that  is  indistinguishable  from  ulcerous 
stomatitis,  would  naturally  lead  us  to  look  to  this  remedy  in  a 
mild  form,  or  at  least  to  some  preparation  of  mercury  as  the 
true  simillimum.  Experience  has  amply  borne  out  the  theory, 
and  placed  mercury  at  the  head  of  the  list  of  homeopathic 
remedies  in  this  affection.  We  have  found  the  mere.  sol.  h. 
3x  eminently  satisfactory  given  in  trituration,  a  powder  of  per- 
haps two  grains  every  three  hours.  This  preparation  of 
mercury  we  have  used  with  prompter  effect  than  any  other 


FOLLICULAR  STOMATITIS.  157 

preparation  of  this  drug.  Some  years  ago  we  had  a  most 
obstinate  and  severe  case  of  stomatitis  ulcerosa,  in  our  Free 
Dispensary,  that  resisted  all  treatment  for  several  weeks.  It 
occurred  in  a  girl  some  eight  or  nine  years  of  age.  The 
mucous  lining  of  the  right  cheek  was  honeycombed  with 
ulceration.  She  was  in  fair  general  condition.  Her  breath 
was  horribly  offensive.  She  had  been  to  other  dispensaries 
previously  without  benefit.  She  was  given  several  remedies — 
mercurius  sol.  3x,  among  others — without  the  slightest  im- 
provement, when  it  occurred  to  me,  that,  as  mercurius  was  so 
clearly  indicated  it  might  be  well  to  try  the  remedy  in  a  higher 
attenuation.  All  other  remedies  were  discarded,  as  well  as  all 
local  treatment,  and  she  was  given  twelve  powders  of  two 
grains  each,  mere.  sol.  30th,  to  be  taken  every  four  hours.  In 
a  week  she  was  greatly  improved  and  the  remedy  continued. 
In  another  week  she  was  discharged  cured.  Since  this  case 
improved  so  much  more  rapidly  under  the  higher  attenuation 
of  mercury — indeed,  she  did  not  improve  at  all  under  the  low — 
we  have  frequently  employed  this  potency  of  the  drug  with 
success. 

The  following  indications  will  assist  in  the  selection  of  the 
remedy  for  the  particular  case  in  hand  : 

Mercurius. — Extensive  ulceration,  fetid  breath,  copious  flow 
of  saliva,  tumefaction  of  submaxillary  glands,  ulcerated  surface 
bleeds. 

Arsenicum  Alb. — Great  exhaustion,  slight  salivation,  co-exist- 
ing diarrhea  of  watery  and  painless  character. 

Baptisia. — Considerable  fever  of  hectic  character;  marked 
general  cachexia;  great  fretfulness  and  restlessness. 

Arum  Triph. — Infant  refuses  drink  and  cries  when  it  is 
offered  ;  saliva  acrid  and  excoriates  the  lips,  causing  sores  on 
lips,  chin  and  cheek. 

Nitric  Acid. — Mouth  dry  and  hot;  gums  swollen,  spongy 
and  bleeding.     Other  symptoms  similar  to  preceding  remedy. 

Follicular  Stomatitis — ^Aphth^. — The  aphthous  form 
of  stomatitis  is  very  different  from  those  forms  that  have 
just  been  described,  but  its  features  are  so  distinct  that  there  is 
very  little  likelihood  of  confusion.  Many  writers  include  all 
forms  of  inflammation  of  the  mouth  under  two  heads,  viz., 
aphthae  and  thrush. 

The  word  "  aphthae  "  itself  is  confusing,  for  it  is  derived 
from  a  Greek  word  meaning  "  to  inflame."  It  has  come,  how- 
ever, by  general  consent,  to  signify  a  form  of  stomatitis  charac- 
terized by  small,  round  ulcers,  which  run  an  acute  course,  and 


158  THE  DISEASES  OF  CHILDREN. 

are  so  different  in  cause  and  character  as  to  be  worthy  of  a  dis- 
tinct name  and  description. 

Causes. — Aphthae  occurs  in  children  between  the  ages  of  two 
and  six  years,  i.  e.,  after  the  suckling  period,  and  is  apparently 
more  often  than  otherwise  due  to  errors  in  diet ;  such,  for  ex- 
ample, as  the  too  free  indulgence  in  pastry  and  sweets  generally. 
It  may,  however,  like  the  other  forms  of  stomatitis,  be  due  to  a 
deranged  state  of  health,  such  as  may  be  left  by  scarlet  fever, 
measles,  whooping,  cough  or  prolonged  gastro-enteritis.  It  is 
most  common  in  springtime  and  autumn,  when  climatic  changes 
are  apt  to  depress  the  system. 

Symptoms. — Aphthae  consists  of  a  number  of  small,  round 
ulcers,  varying  in  size  from  a  pin's  head  to  a  pea,  usually  well 
defined  and  clear  cut,  of  round  or  oval  shape,  and  are  situated 
most  frequently  on  the  lining  membrane  of  the  lower  lip  ;  but 
they  may  be  seen  in  the  furrow  between  the  gum  and  the  cheeks, 
and  occasionally  on  the  latter.  They  are  rarely  found  on  either 
the  palate  or  the  gums.  They  are  quite  superficial  and  are  white 
or  yellowish-white  in  color.  They  are  raised  above  the  level  of 
the  surrounding  tissue  and  are  bordered  by  a  bright  or  livid  ring 
of  inflamed  membrane.  They  have  a  striking  resemblance  to  a 
pearl  or  bead  beneath  the  mucous  membrane,  through  whose 
transparent  wall  they  have  a  glistening  appearance.  As  they 
occupy  the  site  of  the  muciparous  follicles,  they  give  the 
name  of  "follicular"  stomatitis  to  this  variety.  They  are  espe- 
cially vesicular  in  character,  and  soon  after  being  formed  the 
vesicle  ruptures,  leaving  a  shallow  ulcer  with  a  yellowish-gray 
surface,  which  heals  in  the  course  of  a  few  days,  while  fresh 
follicles  are  forming  in  the  near  vicinity.  While  these  pearly 
spots  are  rarely  seen  upon  the  gums  themselves,  their  edges  are 
prone  to  be  inflamed  and  more  or  less  gingivitis  is  quite  common. 
These  ulcers  are  exquisitely  painful  when  touched,  much  more 
so  than  the  inflamed  surface  of  the  other  forms  of  stomatitis. 
This  is  a  distinctive  feature.  When  the  ulcers  are  situated  on 
the  tongue,  they  are  extremely  tender  and  often  prevent  the 
child  from  eating  for  days  together.  There  is  an  increased  flow 
of  saliva,  but  not  to  the  extent  that  occurs  in  other  forms  of 
stomatitis ;  and  there  is  no  offensive  odor  to  the  breath.  Some- 
times two  or  more  ulcers  coalesce  and  make  quite  an  extensive 
sore,  but  this  is  very  rare.  More  often  the  ulcers  are  solitary, 
leaving  patches  of  normal  mucous  membrane  between  them. 
Their  isolated  character,  their  extreme  tenderness  and  sharply 
defined  outlines,  together  with  their  pearly-gray  appearance, 
are  sufficient  to  distinguish  them  from  any  other  affection  of 
the  mouth. 

There  is  generally  an  absence  of  any  but  the  most  trifling 


THRUSH.  159 

symptoms  of  general  disturbance,  although  in  some  cases  there 
may  be  slight  fever,  furred  tongue,  thirst  and  other  symptoms 
of  constitutional  disturbance.  When  symptoms  of  a  graver 
character  than  those  here  indicated  are  present  there  is  some 
co-existing  malady,  to  which  the  aphthae  is  secondary. 

Prognosis. — This  is  always  favorable,  so  far  as  the  aphthae, 
independently  considered,  is  concerned.  When  taken  in  con- 
nection with  other  and  more  serious  conditions  of  health,  they 
may  have  themselves  a  gravity  not  otherwise  possessed. 

Treatment. — In  this  form  of  stomatitis  the  mouth  should  be 
washed  out  often  with  chlorinated  water  or  listerine.  A  good 
wash  if  composed  of  carbolic  acid  or  boric  acid — three  or  four 
grains  to  the  ounce  of  water. 

When  the  aphthous  patches  are  so  tender  as  to  prevent  eat- 
ing, they  may  be  brushed  over  with  a  five-per-ct.  solution  of 
cocaine  before  food  is  taken  or  a  decoction  of  marshmallow  or 
mucilage  of  quince.  The  action  of  these  is  stated  by  Dr.  All- 
chin  to  be  essentially  protective  to  the  raw,  painful  surface,  as 
well  as  being  somewhat  astringent. 

The  remedies  for  internal  use  are  mainly  the  same  as  those 
heretofore  spoken  of  in  the  other  forms  of  stomatitis.  Mer- 
curius  stands  at  the  head  of  the  list.  In  addition  to  the  reme- 
dies already  mentioned,  consult 

Et/msa. — Stools  undigested  ;  much  crying  as  if  from  colic ; 
profuse  salivation  or  its  opposite,  great  dryness  of  mouth. 

Bryonia. — The  mouth  is  usually  dry  with  thirst ;  lips  dry  and 
parched,  rough  and  cracking ;  child  refuses  to  take  the  breast, 
but  when  once  its  mouth  is  moistened,  and  it  is  fairly  at  work, 
it  nurses  well. 

THRUSH.— (MUGUET  ;   SPRUE  ;   PARASITIC  APHTHAE.) 

Character. — This  is  the  form  of  stomatitis  most  common  in 
early  infancy.  It  differs  radically  from  the  other  forms  of  sore 
mouth  which  we  have  been  considering,  in  cause,  nature  and 
gravity.  It  consists  in  the  growth  and  development  upon  the 
mucous  membrane  of  a  peculiar  fungus,  known  formerly  as  the 
oidiufu  albicans,  but  latterly  as  saccharomyces  myoderma. 

Etiology. — Just  how  this  fungus  or  its  spores  gain  an  entrance 
into  the  mouth  of  a  nursing  babe  is  uncertain,  but  it  is  alto- 
gether probable  that  it  is  through  the  contact  with  the  mother's 
nipple.  Bacteriologists  regard  the  fungus  as  identical  with  that 
which  turns  milk  sour,  but  this  point  is  not  fully  determined. 
As  the  disease  is  far  more  prevalent  among  bottle-fed  infants 
than  among  those  nursed  at  the  breast,  it  is  more  than  likely 
that  the  contagium  is  communicated  through  the  bottle  or  the 


160  THE  DISEASES  OF  CHILDREN. 

spoon  used  in  feeding.  The  milk  itself  may  be  a  source  of 
infection. 

A  curious  feature  of  the  matter  is  the  fact  that  in  a  normal 
condition  of  the  mucous  membrane,  this  fungus  will  neither 
grow  nor  develop.  It  must  have  a  diseased  membrane,  or  at 
least  one  not  in  a  perfectly  healthy  condition,  before  it  will  take 
root  and  flourish.  The  extent  to  which  it  does  develop  may 
be  taken  as  a  fairly  accurate  index  as  to  the  extent  to  which 
the  nutrition  of  the  mucous  surface  is  perverted.  An  acid  state 
of  the  secretions  favors  its  development.  It  cannot  thrive  in 
an  alkaline  medium.  Milk  curd  remaining  in  the  mouth,  even 
in  the  smallest  particles,  speedily  turns  sour  and  forms  a  fitting 
soil  for  its  propagation.  Strictly  speaking,  thrush  is  not  a 
special  form  of  stomatitis,  but  requires  a  preceding  stomatitis 
for  its  development.  Some  derangement  of  the  system,  by 
which  nutrition  is  impaired,  and  the  normal  state  of  the  mu- 
cous membrane  altered,  is  an  essential  pre-disposing  element. 

Symptoms. — Thrush  appears  in  the  mouth,  first  as  small, 
pearly-white  patches,  closely  resembling  a  bit  of  milk  curd. 
These  white  spots  or  patches  are  of  varying  sizes,  from  a  pin's 
head  upward.  They  are  most  commonly  found  on  the  buccal 
surface,  but  occasionally  may  develop  in  the  pharynx,  esopha- 
gus, or  other  portion  of  the  digestive  tube.  It  is  quite  prone 
to  add  itself  as  a  complication  of  gastritis  or  entero-colitis.  In 
the  latter  case  it  may  extend  as  far  as  the  anus.  It  does  not 
affect  the  nares,  the  larynx  or  the  bronchial  tubes.  The  first 
stage  of  the  disease,  as  above  indicated,  is  that  of  simple  in- 
flammation. On  this  inflammation  the  point  or  patch  is  devel- 
oped, and  is  first  white  and  afterward  turns  faintly  yellow. 
The  center  of  each  is  more  elevated  than  the  margin.  They 
are  easily  detached  by  a  little  force,  but  are  quickly  reproduced 
again.  Their  highest  elevation  is  not  more  than  a  line  above 
the  surface.  They  tend  to  spread  with  great  rapidity,  so  that 
a  single  point,  at  first  scarcely  visible,  may  extend  in  three  or 
four  days  so  as  to  cover  the  greater  portion  of  the  mucous 
lining  of  the  mouth.  From  the  first  there  are  the  usual  symp- 
toms accompanying  the  simple  form  of  stomatitis,  such  as  rest- 
lessness, fretfulness,  slight  fever,  and  pain  when  nursing  is 
attempted.  There  is  not  the  same  amount  of  salivation  as  in 
other  forms  of  stomatitis,  the  mouth  being  rather  dry  and  hot. 
There  is  no  fetor  of  the  breath.  In  severe  cases,  the  intestinal 
tube  is  always  affected  and  the  infant  has  thirst,  loss  of  appe- 
tite, vomiting  and  diarrhea.  Rapid  emaciation  follows  as  a 
natural  consequence;  and  if  the  disease  is  not  arrested,  a  state 
of  dangerous  prostration  may  be  speedily  reached. 

Prognosis. — The  duration  of  thrush  varies  according  to  its 


GANGRENE  OF  THE  MOUTH.  161 

intensity,  and  the  favorable  or  unfavorable  condition  of  the  in- 
fant. Under  favorable  conditions  it  may  be  cured  in  three  or 
four  days,  but  under  unfavorable  conditions  it  may  last  for 
weeks,  unless  death  supervene  sooner.  When  thrush  occurs 
in  connection  with  gastro-enteritis,  the  mortality  is  very  great ; 
and  occurring  in  the  course  of  any  exhausting  disease  it  is  an 
unfavorable  omen.  As  it  is  most  common  during  the  first  few 
weeks  of  life,  when  the  reactive  powers  of  the  system  are 
feeble,  the  prognosis  is  correspondingly  doubtful.  In  itself, 
however,  thrush  is  not  a  serious  malady.  Its  grave  aspect  is 
due  to  the  low  state  of  vitality  or  the  co-existing  derangements 
with  which  it  is  associated. 

Treatment. —  From  what  has  been  said  regarding  the  cause 
and  nature  of  thrush,  the  first  object  of  treatment  should  be  to 
correct  the  acid  condition  of  the  mouth  which  favors  the 
growth  and  spread  of  the  fungus.  This  can  only  be  accom- 
plished by  the  most  scrupulous  cleanliness,  and  by  repeatedly 
washing  the  mouth  with  some  alkaline  lotion,  such  as  borax  or 
sulphide  of  soda.  One  or  the  other  of  these  lotions  should  be 
used  after  each  meal,  and  care  should  be  taken  to  reach  every 
point  of  the  infected  mucous  membrane.  Attention  should  be 
given  to  the  general  health,  and  the  medication  should  be 
adapted  to  the  totality  of  the  symptoms,  of  which  the  obvious 
thrush  may  be  but  a  minor  factor.  For  this  reason,  the  remedies 
which  we  have  already  named  as  suitable  for  other  forms  of 
stomatitis,  or  which  might  be  considered  as  indicated,  were  the 
malady  a  purely  local  one,  must  be  abandoned  for  such  drugs  as 
will  reach  not  only  the  inflamed  mucous  membrane  of  the 
mouth,  but  extend  their  influence  to  the  whole  digestive  tract. 
In  other  words,  constitutional  remedies  are  called  for,  to  correct 
the  constitutional  dyscrasia  underlying  the  local  symptoms. 
Mercurius  is  one  of  those  deep-acting  remedies  that  will  often 
be  found  to  cover  the  entire  case.  Calcarea  carb.  is  another. 
Besides  these  consult  carto.  veg.  china,  and  arsenicum. 

GANGRENE   OF  THE   MOUTH. — (CANCRUM   ORIS.) 

Definition  —  Frequency.  —  The  term  "  cancrum  oris,"  by 
which  this  disease  is  sometimes  known,  is  apt  to  mislead  one 
to  suppose  it  the  same  as  "  canker  sore  mouth,"  by  which 
term  the  laity  are  wont  to  designate  the  aphthous  form  of 
stomatitis.  The  latter,  as  we  have  seen,  is  generally  a  trifling 
malady  and  attended  with  little  danger,  while  the  former  is 
among  the  most  fatal  of  early  life.  It  is  fortunately  a  very 
rare  disease  in  this  country,  and  even  among  the  poor  and 
densely  crowded  districts  of  London,  it  is  met  with  but  rarely. 
D.  C— 11 


162  THE  DISEASES  OF  CHILDREN. 

At  the  East  London  Hospital  for  Children  during  seven  years 
— from  1 88 1  to  1887  inclusive — out  of  a  total  number  of  six 
thousand  three  hundred  and  sixty-four  admissions,  there  were 
only  five  cases,  and  in  the  Hospital  for  Sick  Children,  Great 
Ormond  St.,  during  thirteen  years  ending  in  1888,  with  a  total 
admission  of  nearly  thirteen  thousand  patients,  there  were  but 
six  cases.  We  have  no  statistics  of  the  disease  in  this  country, 
but  can  state  that  during  the  past  seventeen  years,  not  a  single 
case  has  been  seen  at  the  Central  Free  Dispensary  in  this  city 
(Chicago),  and  in  a  private  practice  extending  over  nearly 
thirty  years,  we  have  seen  but  one  case.  It  is  usually  of 
secondary  origin  and  consists  of  a  rapidly  progressing  necrosis 
of  the  cheek  or  gum,  which  is  usually  fatal,  and  is  recovered 
from  only  with  permanent  loss  of  tissue.  It  seems  to  be  much 
more  common  among  females  than  males,  and  more  frequent 
between  the  ages  of  two  and  five  years  than  subsequently.  It 
is  common  to  the  low-lying,  damp  countries,  such  as  Holland 
and  parts  of  Sweden,  where  it  is  almost  endemic.  It  is  not 
contagious.  Some  previous  disease,  which  has  left  the  general 
health  in  an  impaired  condition,  or  some  mal-hygienic  influence 
seriously  lowering  the  standard  of  vitality,  is  necessary  for  its 
production.  For  some  unexplained  reason,  more  than  one- 
half  of  the  recorded  cases  have  followed  closely  after  measles. 
A  few  cases  have  been  observed  to  follow  scarlet  fever  and 
the  other  eruptive  fevers.  Simple  or  ulcerous  stomatitis  often 
precedes  it. 

Anatomical  Characters. — The  parts  most  subject  to  attack 
of  gangrene  are  the  inside  of  the  cheek,  which  first  becomes 
inflamed,  then  thickened  and  indurated.  This  induration  ex- 
tends rapidly  and  the  dark  hue  of  gangrene  appears,  followed 
soon  by  sloughing  of  the  portion,  the  vitality  of  which  is  lost. 
As  the  disease  progresses  it  does  not  incline  to  attack  the 
blood-vessels,  but  leaves  them  exposed  while  it  burrows 
amidst  the  softer  tissues  till  it  reaches  and  penetrates  the  skin 
of  the  cheek  outside.  At  the  same  time  it  extends  downward 
to  the  deeper-seated  structure  of  the  jaw,  where  it  loosens  one 
or  more  of  the  teeth.  If  its  progress  be  not  arrested,  it  attacks 
the  periosteum  of  the  maxillary  bone,  destroying  the  gum  and 
teeth  and  denuding  the  alveoli.  Wherever  it  reaches,  the 
tissues  are  irreparably  destroyed. 

Symptoyns. — The  first  symptom  to  be  observed  is  in  the  mouth, 
where  a  point  of  inflammation  presents  all  the  visible  signs  of 
simple  stomatitis.  Very  soon,  however,  there  ensues  a  thick- 
ening of  the  surrounding  tissue.  The  mucous  membrane  pre- 
sents a  dark-red  appearance  for  the  distance  of  a  few  lines 
beyond  the  point  of  gangrene,  which  point  marks  the  seat  of 


GANGRENE  OF  THE  MOUTH.  163 

the  initial  lesion.  This  dark-red  portion  covers  tissues  which 
are  inflamed  and  indurated  and  about  to  become  gangrenous. 
As  the  disease  approaches  the  surface  of  the  cheek,  a  livid  cir- 
cular spot  is  noticeable  on  the  skin  corresponding  to  the  al- 
ready necrosed  portion  of  the  mucous  membrane  within  the 
mouth.  The  tongue  is  usually  swollen,  but  moist ;  there  is  lit- 
tle or  no  fever,  and  the  indications  of  suffering  are  not  at  all  in 
proportion  to  the  gravity  of  the  disease  which  is  in  progress. 
As  gangrene  is  rarely,  if  ever,  a  primary  affection,  its  symptoms 
are  not  easily  separated  from  the  general  pathological  state 
which  accompanies  it.  There  is  progressive  prostration  as  the 
disease  advances.  The  body  and  limbs  emaciate  and  the  eyes 
are  hollow  and  the  lids  edematous.  Sometimes  the  child  is 
fretful,  at  others  dull  and  indifferent.  The  pain  is  never  as 
great  as  in  some  forms  of  stomatitis,  which  are  devoid  of  dan- 
ger. If  the  cheek  is  perforated,  it  interferes  with  alimentation 
to  such  a  degree  that  the  appearance  of  the  child  becomes  piti- 
able. The  saliva  flows  from  the  mouth  either  pure  or  mixed 
with  blood  and  offensive  matter. 

Except  in  very  mild  cases,  there  is  a  distinctively  gangrenous 
odor.  There  is  usually  great  thirst,  and  the  appetite,  though 
sometimes  poor,  is  often  good  throughout  the  entire  course  of 
the  disease.     There  is  no  vomiting,  nor  are  the  bowels  affected. 

Prognosis. — The  majority  of  children  affected  with  noma  die, 
either  from  exhaustion  or  from  fatal  hemorrhage,  which  results 
from  the  destruction  of  continuity  in  one  of  the  blood-vessels. 
In  many  cases,  however,  which  reach  a  fatal  termination,  there 
is  no  hemorrhage,  in  consequence  of  coagulation  in  the  vessels. 
The  prognosis  is  materially  affected  by  the  amount  and  nature 
of  the  cachexia  associated  with  it.  If  it  occurs  as  a  sequel  to 
a  disease  which  has  materially  sapped  the  vigor  of  the  patient, 
and  co-existing  symptoms  indicate  a  serious  condition  of  mal- 
nutrition, the  outlook  is  obviously  poor;  but  if  the  general 
health  is  in  a  fair  condition  and  assimilation  is  not  hopelessly 
impaired,  there  may  be  a  chance  to  arrest  the  gangrene  before 
it  has  reached  a  necessarily  fatal  stage.  If  the  disease  has  in- 
volved the  maxillary  bone,  recovery  takes  place  with  the  per- 
manent loss  of  teeth,  and  the  patient  may  lose  the  free  use  of 
the  jaw.  The  separation  of  necrosed  bone  in  such  cases  is 
slow  and  tedious. 

Treatment. — As  gangrene  of  the  mouth  is  pre-eminently  a 
disease  of  debility,  the  most  obvious  necessity  of  treatment  is 
to  bring  about,  if  possible,  the  most  rapid  restoration  of  the 
general  health.  All  anti-hygienic  influences  must  be  removed, 
and  the  most  nourishing  food  given.  Old-school  writers  recom- 
mend ferruginous  preparations  and  the  bitter  tonics,  such  as 


164  THE  DISEASES  OF  CHILDREN. 

quinia,  quassia,  etc.  Cod-liver  oil  is  also  recommended.  The 
nature  of  the  disease  is  such,  that  a  prompt  arrest  of  the  de- 
structive process  is  most  desirable,  and  for  this  purpose,  some 
escharotic  is  a  necessity.  M.  Taupin  advises,  after  removing  a 
considerable  portion  of  the  gangrenous  tissues  with  scissors, 
the  application  of  strong  muriatic  acid,  and  when  the  slough  is 
detached,  of  dry  chloride  of  lime. 

Dr.  Coates,  in  the  Children's  Asylum,  uses  the  following 
formula,  which  is  indorsed  by  others  who  have  used  it : 

g-     Cupri  sulph 3  "• 

Pulv.     cinchona 3  ss. 

Aqua S  ^^-        Misce. 

This  is  to  be  applied  twice  a  day  very  carefully  to  the  full 
extent  of  the  ulcerations  and  excoriations.  "  The  addition  of 
the  cinchona  is  only  useful  by  retaining  the  sulphate  of  copper 
longer  in  contact  with  the  edge  of  the  sore."  Dr.  Coates  has 
also  found  a  solution  of  the  sulphate  of  zinc,  31  to  an  ounce  of 
water,  by  itself  or  combined  with  tincture  of  myrrh,  to  be 
useful. 

The  odor  which  comes  from  the  gangrenous  mass  is  not  only 
very  offensive  to  those  who  are  associated  with  the  case,  but 
has  a  deleterious  effect  upon  the  child,  who  is  constantly  inhal- 
ing it.  Some  antiseptic  and  deodorizer  is  therefore  essential, 
the  best  of  which  is  a  strong  solution  of  permanganate  of  potass., 
with  which  the  sore  may  be  bathed  as  often  as  necessary.  Lis- 
terine  is  also  very  useful  for  this  purpose. 

The  remedies  which  are  most  likely  to  be  useful  in  this  affec- 
tion are  arsenicum,  thuja,  mercurius  and  lachesis.  The  best 
preparation  of  mercurius  for  this  affection  is  mere,  dulcis.  The 
indications  for  arsenicum  have  already  been  given.  Lachesis 
is  characterized  by  fetor  of  breath,  gangreneous  ulcerations, 
black  and  humid  gangrene,  salivation,  and  hemorrhages.  The 
pathogenesis  of  thuja  is  such  as  would  suggest  its  usefulness 
in  this  disease,  but  we  are  not  aware  that  it  has  ever  been  thus 
employed.  Phosphoric  acid  is  a  remedy  likely  to  be  service- 
ble  in  cases  having  painless  diarrhea  and  in  children  who  are 
syphilitic.  It  is  all  the  more  indicated  if  the  gangrene  follows 
measles  in  children  with  inherited  taint. 


CHAPTER   II. 

ESOPHAGITIS. 

Inflammation  of  the  esophagus  occurs  but  rarely  in  in- 
fancy and  childhood,  but  often  enough  to  require  a  brief  con- 
sideration. 

Causes. — It  occurs  most  often  in  bottle-fed  babies,  and  is  due 
to  giving  food  either  too  hot  or  too  cold.  Foods  also  which 
give  rise  to  acidity  of  the  stomach  with  attendant  eructations 
of  irritating  gases  may  give  rise  to  it.  Occasionally  it  is  due  to 
an  extension  of  stomatitis,  either  the  simple  or  ulcerous  form, 
or  of  thrush  from  the  mouth  into  the  gullet.  The  accidental 
swallowing  of  acrid  substances,  such  as  acids  or  alkalies,  may 
be  the  cause,  the  irritant  producing  stomatitis  and  gastritis  at 
the  same  time. 

Anatomical  Characters. — The  inflamed  surface  of  the  esoph- 
agus does  not  always  present  a  uniform  appearance.  The  in- 
flammation, instead  of  being  spread  over  the  mucous  membrane 
with  equal  intensity,  is  more  apt  to  show  itself  in  streaks  or 
patches.  Dr.  J.  Lewis  Smith  says  that  he  has  frequently 
observed  at  autopsies  a  greater  degree  of  inflammation  in  the 
lower  than  the  upper  half  of  the  esophagus,  even  in  cases  where 
the  infant  had  stomatitis  at  the  time  of  death. 

Symptoms. — The  symptoms  of  esophagitis  in  infants  are  not 
very  clearly  defined.  There  is  pain  when  efforts  at  deglutition 
are  made,  but  the  pain  is  not  intense,  nor  are  there  other  indi- 
cations of  any  peculiar  distress.  Vomiting  is  not  common — at 
least,  there  is  no  vomiting  that  can  be  referable  to  the  esopha- 
geal inflammation.  As  the  disease  is  generally  an  accompani- 
ment or  an  extension  of  stomatitis  downward,  or  of  intestinal 
inflammation  upward,  its  symptoms  are  generally  masked  by 
those  of  the  primary  disease. 

Treatment.  —  When  the  latter  is  the  case,  remedies  ad- 
dressed to  the  primary  affection  are  the  proper  ones  for 
esophagitis,  and  no  special  medicines  are  required  for  its  cure. 
Attention  should  be  given  to  the  diet,  however,  and  all  foods 
should  be  excluded  from  the  dietary  which  are  likely  to 
cause  acidity  of  the  stomach  or  which  conduce  to  indigestion 
in  any  form. 

(165) 


166  THE  DISEASES  OF  CHILDREN. 

GASTRITIS. — (gastric   CATARRH.) 

Inflammation  of  the  stomach  is  not  common  among  infants 
nursed  at  the  breast,  although  nursing  women  may,  by  errors 
in  diet  or  by  reason  of  ill-health  in  themselves,  or  from 
other  causes,  convey  to  the  nursling  a  congestion  of  the 
mucous  follicles  of  the  stomach  of  more  or  less  serious  char- 
acter. Among  children  who  are  well  born  and  have  a  good 
general  development  at  birth,  slight  derangements  in  the 
condition  of  the  mother  or  wet-nurse  do  not  produce  appre- 
ciable symptoms  of  indigestion,  as  a  rule.  There  are  ex- 
ceptions to  this,  however.  Billard  and  other  observers  have 
seen  cases  of  acute  gastritis  in  young  infants  who  had  taken 
nothing  of  an  irritating  character  into  the  stomach.  In 
connection  with  inflammation,  either  of  the  mouth  or  of 
the  intestines,  gastritis  is  by  no  means  uncommon.  In  such 
cases  the  trouble  arises  from  extension  of  the  primary  dis- 
order along  the  mucous  tract.  Undoubtedly  the  most  com- 
mon form  of  indigestion  in  infancy  is  that  which,  at  first  at 
least,  involves  function  only,  and  does  not  necessarily  imply 
a  pathological  change  in  the  stomach  itself.  It  would  be 
wrong  to  include  such  cases  in  a  consideration  of  the  sub- 
ject of  inflammation  of  the  stomach,  and  we  shall  consider 
them  in  the  succeeding  section,  under  the  head  of  Congenital 
Dyspepsia. 

The  term  gastritis  is  here  restricted  to  those  cases  of  stomach 
disorder  wherein  there  is  not  merely  a  slight  indigestion,  but 
other  evidences  of  impairment  of  function  due  to  organic  lesion. 
This  lesion  may  be,  and  often  is,  slight  in  its  incipiency ;  but  it 
is  sufficient  to  retard  growth  and  render  its  subject  peevish, 
fretful  and  sick,  and  if  not  arrested  it  may  easily  and  quickly 
compromise  life  itself. 

Causes. — Defective  feeding  is  by  all  means  the  most  prolific 
cause  of  gastric  catarrh  in  infants,  and  it  is  amazing  what  serious 
consequences  may  result  from  a  very  trifling  departure  from 
strict  physiological  requirements  in  the  matter  of  food.  In 
nurslings,  if  the  milk  of  the  wet-nurse  is  a  little  too  old,  or  if  the 
infant  is  put  to  the  breast  too  often,  a  condition  of  irritability  is 
set  up  which  ultimately  results  in  inflammation  or  gastric 
catarrh.  Insuflficient  clothing  may  result  in  a  sudden  check  to 
the  cutaneous  circulation,  or  too  rapid  cooling  of  the  body  after 
being  heated  in  play  may  cause  a  congestion  of  the  mucous 
membrane  of  the  stomach,  when  a  comparatively  trifling  error 
in  diet,  which  under  other  circumstances  would  do  no  harm 
whatever,  may  now  result  in  a  derangement  of  serious  character. 
A  neglect  of  sanitary  precautions,  such  as  air,  light,  exercise  and 


GA  S  TRI TIS—S  7' MP  TOMS.  167 

ventilation  ;  the  depressing  influences  of  dentition  and  the  acute 
ailments  and  specific  fevers,  so  common  in  childhood  ;  any  or 
all  of  these  may  reduce  the  nervous  force  and  bring  about 
derangement  of  the  complicated  functions  of  digestion.  An 
inflammation  of  considerable  extent  and  serious  type  may  be 
produced  by  the  infant  swallowing  liquids  which  are  too  hot  or 
too  cold,  or  containing  spices  or  other  irritants,  which  inflame 
the  esophagus  first  and  the  stomach  afterward.  We  once  saw 
a  case  of  acute  gastritis  in  an  infant  less  than  a  year  old  caused 
by  tartar  emetic  in  the  third  decimal  trituration.  The  attack 
lasted  for  some  days  and  was  attended  with  constant  vomiting 
and  retching. 

Symptoms. — The  first  noticeable  departure  from  a  state  of 
health  in  cases  of  gastritis  is  shown  is  loss  of  apetite  with  vom- 
iting of  ingested  food  or  drink.  Nausea,  as  evidenced  by  gag- 
ging, is  an  early  symptom  and  this  is  soon  replaced  by  persistent 
throwing  up  of  everything  taken  into  the  stomach.  If  milk  is 
taken,  it  comes  from  the  stomach  curdled.  The  vomiting  is 
not  ended  with  the  ejection  of  food  ;  it  continues  until  mucus 
and  perhaps  bile  are  expelled.  The  tongue  soon  becomes 
coated  along  its  center  with  a  white,  moist,  pasty  coating,  while 
the  edges  are  red  and  glazed.  The  papillae  of  the  tongue  are 
raised  and  project  through  the  coating,  dotting  the  organ  with 
bright  red  spots.  Other  portions  of  the  mucous  membrane  are 
apt  to  be  involved,  so  that  coryza  or  mucus  purging  may  be 
present.  Under  such  circumstances  it  is  often  thought  that  the 
child  has  taken  cold,  and  a  mistaken  diagnosis  may  lead  to 
medication  of  the  air  passages.  After  a  variable  time,  normal 
digestion  may  return,  sometimes  rapidly,  but  more  often  slowly. 
Repeated  attacks  speedily  influence  the  general  health,  which 
again  reacts  upon  the  stomach  and  favors  an  early  recurrence  of 
the  trouble.  There  is  sometimes  considerable  elevation  of 
temperature  in  these  cases,  but  often  in  mild  attacks  there  is  no 
perceptible  pyrexia.  Tenderness  over  the  epigastrium  is  not  a 
constant  symptom,  nor  is  it  ever  extreme.  Pain  is  felt  in  the 
region  of  the  stomach  if  the  disease  is  acute,  especially  after 
eating ;  but  often  the  pain  is  so  slight  as  to  be  hardly  notice- 
able. The  breath  is  foul  and  the  flow  of  saliva  may  be  much 
increased.  Herpetic  blisters  (hydroa)  are  apt  to  appear  about 
the  mouth,  especially  if  the  systemic  disturbance  is  great. 
Nervous  symptoms  are  very  common,  sometimes  of  a  con- 
vulsive character,  and  at  others  a  disturbance  of  the  mental 
state  is  noticeable.  Cases  of  aphasia  have  been  observed  by 
Henoch  and  others  from  this  cause.  Very  young  children 
may  have  spasms  that  are  either  tonic  or  clonic,  or  both 
states  may  be  present. 


168  THE  DISEASES  OF  CHILDREN. 

There  may  be  a  disturbance  of  the  respiratory  function  amount- 
ing in  some  to  croup  of  the  spasmodic  variety,  and  in  others  to 
dyspeptic  or  gastric  asthma. 

The  diagnosis  of  acute  gastritis  is  much  easier  that  when  it 
presents  itself  in  a  chronic  form.  In  the  former  case  vomiting, 
rapid  emaciation  and  epigastric  pain  are  the  chief  points  to  be 
considered,  while  in  the  latter  our  diagnosis  is  often  obscured 
by  the  ill-defined  character  of  the  symptoms,  and  also  by  the 
presence  of  symptoms  having  but  a  remote  relation  to  the 
stomach. 

Where  persistent  vomiting  is  present,  however,  and  steady 
emaciation  progresses  out  of  proportion  to  the  gravity  of  co-ex- 
isting symptoms,  gastritis  is  doubtless  present,  whether  there 
be  pain  in,  or  tenderness  over,  the  stomach  or  not. 

In  uncomplicated  cases  the  bowels  are  apt  to  be  constipated, 
but  there  is  nearly  always  a  diarrhea  from  the  presence  of 
entro-colitis. 

Prognosis. — Unless  the  inflammation  is  so  severe  or  so  pro- 
tracted as  to  disintegrate  the  mucous  membrane  of  the  stomach, 
there  is  no  reason  why  it  may  not  yield  to  judicious  treatment 
and  subside  before  the  life  of  the  infant  is  compromised.  When 
the  inflammation  is  associated  with  severe  thrush,  the  chances 
are  unfavorable,  and  the  same  is  true  with  entero-colitis.  When 
death  ensues,  it  is  generally  from  exhaustion. 

Treattnent. — The  first  thing  to  be  done  in  cases  of  gastritis  is 
to  ascertain  the  cause  of  the  inflammation,  for  so  long  as  the 
cause  is  operative,  the  inflammation  will  continue.  If  this  be 
in  the  mother's  milk,  the  infant  should  be  weaned  at  once,  or 
a  suitable  wet-nurse  substituted. 

If  bottle-fed,  the  habitual  food  should  be  changed  to  that 
which  is  more  bland  and  unirritating.  Barley  water,  rice 
water,  or  arrowroot  should  be  given  in  place  of  foods  less  easily 
digested.  Cream  should  be  substituted  for  milk  temporarily, 
and  in  cases  of  great  prostration,  when  all  food  is  rejected  from 
the  stomach,  nutritive  enemata  may  be  used  to  great  advan- 
tage. Murdock's  food  is  admirably  adapted  for  this  purpose, 
and  a  child  can  be  nourished  by  it  per  rectum  for  a  consider- 
able time.  In  some  cases  it  is  absolutely  useless  to  attempt  to 
use  the  stomach  for  alimenation  until  the  inflammation  sub- 
sides. Not  long  since  we  saw  a  case  of  this  kind  in  consulta- 
tion with  our  friend,  Dr.  S.  P.  Hedges.  The  patient  was  an 
infant  about  a  year  old.  At  the  time  of  my  first  visit  the 
stomach  would  retain  nothing — not  even  water.  Champagne  in 
a  few-drops  doses,  was  instantly  ejected ;  koumiss  had  been 
tried  without  avail.  The  infant  was  desperately  thirsty  and 
clutched  a  cup   of  water  with  the  greatest  avidity.     Under 


GASTRITIS— REMEDIES.  169 

these  circumstances,  even  medication  by  the  stomach  was  out 
of  the  question.  The  attack  was  an  acute  one  and  the  child 
had  been  previously  in  good  health.  It  was,  therefore,  well 
nourished  and  it  was  decided  to  give  the  stomach  perfect  rest 
for  a  day  or  two.  Nutritive  enemata  were  given  at  intervals 
and  in  the  course  of  a  couple  of  days  the  stomach  had  so  far 
recovered  that  barley  water  was  retained  and  digested.  A 
week  later  the  gastritis  had  entirely  disappeared  and  did  not 
recur.  Since  there  is  an  excess  of  acid  in  all  mucous  inflam- 
mations, lime  water  or  bicarb,  of  soda  should  be  mixed  with 
the  milk,  if  the  latter  is  tolerated.  Cloths  wrung  out  of  hot 
water  and  placed  over  the  stomach  are  very  helpful,  or  a  poul- 
tice of  ground  flaxseed  applied  hot  and  covered  with  oil  silk. 

REMEDIES. 

Aconite. — In  the  beginning  of  an  attack. 

Bryonia. — Abdomen  distended  with  gas  and  tender  to  the 
touch,  violent  thirst,  cold  hands  and  feet. 

Belladonna. — Pupils  dilated;  stupor;  empty  retching;  symp- 
toms indicating  encephalic  fever ;  jerking  and  twitching  of 
muscles.  Hartmann  says  that  bryonia  and  belladonna  are  par- 
ticularly suitable  if  the  symptoms  of  gastritis  develop  them- 
selves shortly  after  the  child  is  weaned. 

Ipecacuanha. — Vomiting  and  retching  continually,  with  other 
characteristic  symptoms. 

Calcarea  Carb. — The  intestinal  canal  seems  to  be  more 
affected  than  the  stomach ;  tendency  to  diarrhea  more  marked 
than  the  urging  to  vomit ;  passages  smell  sour  and  have  the 
color  of  clay ;  great  restlessness  and  debility ;  especially  indi- 
cated if  the  child  is  teething. 

Kreasotum. — This  remedy  is  highly  recommended  by  Jahr^ 
who,  however,  does  not  give  the  special  indications  for  its  use. 
He  says :  "  Before  I  became  acquainted  with  the  splendid 
virtues  of  kreasotum  I  had  already  lost  three  cases  of  gastritis, 
whom  I  had  treated  with  calcarea  and  arsenicum.  Since  I 
have  used  kreasotum  I  have  not  met  with  a  single  loss." 

Tartar  Emetic. — Frequent  sour  vomiting;  empty  retching 
and  straining  to  vomit,  with  ineffectual  urging  to  diarrheaic  stool, 
or  with  slimy  diarrhea ;  drowsiness  with  contracted  pupils,  quiet 
breathing  and  very  bad  humor ;  the  child  cannot  be  touched 
without  causing  it  to  cry.  "The  drowsiness  and  contracted 
pupils  are  characteristic  indications  for  tartar  emetic,  whereas 
a  condition  bordering  on  soper  speaks  more  in  favor  of  bella- 
donna." 

Arsenicum,    Veratrum    Alb.    and   Phosphoric  Acid,   are  all 


170  THE  DISEASES  OF  CHILDREN. 

spoken  of  favorably  by  those  who  have  a  right  to  speak 
authoratively  on  the  subject. 

Argentum  Nitras. — This  remedy,  although  the  last  on  the 
list,  is  by  no  means  considered  the  least  valuable  by  those  who 
have  used  it.  It  is  more  clearly  homeopathic  to  a  pure 
gastritis  than  any  drug  hitherto  mentioned.  The  indications 
for  its  employment  are:  excessive  flatulence,  the  stomach 
seems  ready  to  burst,  copious  eructations,  which  are  accom- 
plished only  after  persistent  effort,  and  are  very  violent.  The 
patient  is  in  a  condition  of  apathy. 

If  the  child  is  old  enough  to  describe  his  symptoms,  he  com- 
plains of  great  burning  in  the  stomach.  This  last  symptom  is 
very  characteristic. 

Dr.  William  Pepper,  in  the  "Cyclopedia  of  Diseases  of  Chil- 
dren," vol.  III.,  page  i6,  thus  speaks  of  this  drug:  "There  is  no 
remedy  which  can  be  given,  even  to  the  youngest  infant,  with 
more  confidence  than  nitrate  of  silver  in  those  cases  where  the 
gastric  irritability  is  excessive,  so  that  vomiting  is  a  chronic 
condition.  Indeed,  in  all  the  catarrhal  affections  of  the  gastro- 
intestinal mucous  membrane  in  children,  this  remedy  possesses 
remarkable  value,  although  it  requires  great  tact  to  determine 
the  dose  and  the  frequency,  and  times  of  administration  best 
adapted  to  each  case." 

Dr.  Pepper  gives  a  formula  for  its  exhibition  containing  one- 
sixtieth  of  a  grain  {sic)  at  a  dose,  dissolved  in  a  teaspoonful  of 
water.     Our  3»  trit.  dissolved  in  water  is  far  more  effective. 


CHAPTER  III. 

CONGENITAL  DYSPEPSIA. 

This  term  is  used  deliberately  to  designate  certain  forms  of 
indigestion  attended  by  mal-assimilation,  and  yet  which  do  not 
exhibit  any  of  the  recognizable  signs  of  inflammation  ;  nor  are 
they  found  post  mortem,  to  have  any  appreciable  lesion  in  the 
•digestive  canal.  There  is  no  pathological  change  in  the  mu- 
cous membrane  of  the  stomach  ;  there  is  no  rise  in  temperature 
to  indicate  pyrexia ;  there  is  wasting,  steady  and  persistent 
atrophy ;  and  yet  no  clue  to  the  cause  of  the  trouble  save  that 
of  functional  indigestion.  These  cases  occur  often  in  young 
infants  who,  soon  after  birth  and  without  apparent  cause,  fall 
into  a  state  of  decline  and  fail  to  grow  and  thrive  as  a  well- 
nourished  infant  ought  to  do,  and  yet  whose  earliest  morbid 
symptoms  are  very  different  from  those  dependent  on  tuber- 
culosis, rachitis,  or  other  of  the  well-marked  cachexias. 

Marasmus  is  the  term  which  has  most  commonly  been  used 
to  describe  these  cases,  but  they  are  also  referred  to  under  the 
head  of  atrophy,  inanition,  wasting,  and  recently  MM.  Parrot 
and  Robin  have  proposed  a  new  term,  athrepsia,  which,  from 
its  derivation,  is  eminently  scientific  and  clearly  descriptive ; 
but  as  this  term  has  not  as  yet  come  into  general  use,  I  prefer 
the  more  familiar  word  "  dyspepsia  "  to  any  other,  as  indicating 
not  only  the  nature  of  the  disease,  but  also  its  cause,  which  is 
in  all  cases  a  fault  or  failure  of  the  digestive  function.  In  a 
given  case  the  fault  may  be  in  the  organs  of  assimilation ;  in 
another,  in  an  insufficiency  or  inefficiency  of  the  liver ;  and 
again,  the  trouble,  so  far  as  we  can  tell,  is  due  solely  to  a  lack 
of  innervation,  in  which  case  the  stomach  is  wanting  in  nerv- 
ous tone,  in  stamina,  in  digestive  power.  In  any  case  there  is 
the  prime  condition  of  indigestion  or  dyspepsia,  and  as  a  result 
thereof  we  have  mal-nutrition. 

Most  of  these  babies  of  which  I  speak,  are  plump  and  well- 
nourished  enough  at  birth,  and  it  is  only  after  weeks,  or  months 
in  some  cases,  before  any  serious  impairment  of  nutrition  be- 
comes noticeable,  athough,  in  most  cases,  this  is  manifest  at  an 
earlier  period,  and  in  all  cases,  the  proximity  to  birth,  when 
more  or  less  failure  becomes  apparent,  warrants  the  presump- 
tion that  the  cause  of  the  trouble  is  ante-  rather  than  post- 

(171) 


172  THE  DISEASES  OF  CHILDREN. 

natal,  and  that  the  designation  of  congenital  dyspepsia  is  not 
inappropriate. 

That  some,  if  not  many,  of  these  cases  are  not  only  congenital, 
but  involve  also  the  question  of  heredity,  will  be  apparent  from 
cases  to  be  cited  hereafter. 

I  am  fully  aware  of  the  fact  that  some  defect  in  the  milk  of 
the  mother  or  nurse,  is  a  prolific  source  of  trouble  in  the  early 
period  of  infancy;  and  a  badly-selected  food  in  bottle-fed  chil- 
dren may  quickly  disorder  the  stomach ;  but  the  infants  here 
referred  to  are  inclined  to  waste  and  decline,  and  grow  thinner 
and  thinner  on  the  best  of  food  ;  and  indeed  the  better  the  food, 
the  more  they  fail  to  thrive. 

With  some  babies,  the  slightest  indiscretion  in  the  mother's 
diet  gives  rise  to  complaint,  while  with  other  children  the  same 
mother  may  eat  fruit  and  vegetables,  and  enjoy  the  widest  lati- 
tude in  eating  with  impunity. 

These  cases  of  congenital  dyspepsia  may  be  readily  differen- 
tiated from  the  acute  and  accidental  disorders  of  the  alimen- 
tary canal,  such  as  gastritis,  enteritis,  entero-colitis,  etc.,  not 
only  by  the  generally  well-marked  peculiarities  of  these  latter 
affections,  but  by  the  added  fact  that  with  them  we  have  a 
period  of  health,  and  growth,  and  thrift,  preceding  the  invasion 
of  disease  or  decline,  and  usually,  especially  in  serious  forms  of 
these  diseases,  we  have  more  or  less  fever  with  its  attendant 
and  unmistakable  symptoms. 

In  congenital  dyspepsia,  we  have  a  steady  and  progressive, 
but  slow  emaciation ;  an  unsatisfied  craving  for  food  which  en- 
genders restlessness,  wakefulness,  and  distressful  crying;  but 
there  is  an  absence  of  pyrexia,  excepting,  perhaps,  occasional 
and  slight  febrile  movements  of  an  irritative  character,  which 
are  transient  in  duration. 

The  importance  of  recognizing  these  cases,  and  distinguish- 
ing them  from  other  cachexias  arises  from  the  fact  that  if  there 
be  only  functional  impairment,  as  is  usually  the  case,  the  prog- 
nosis is  much  more  favorable  than  it  can  be,  if  a  more  profound 
morbid  tendency  be  present,  involving  constitutional  taint ;  and 
the  medicinal  and  hygienic  management  of  these  cases  must 
be  very  different  from  what  they  would  be  of  necessity  under 
the  latter  circumstances. 

Two  illustrative  cases  will  serve  to  indicate  what  is  here 
meant  by  congenital  dyspepsia : 

Case  I. — Baby  E.,  female,  born  December  5,  1880.  at  full 
term;  weighed  eight  to  nine  pounds;  slept  most  of  the  time 
during  the  first  few  days ;  its  passages  were  normal  and  regu- 
lar, and  indeed  the  baby  seemed  perfectly  healthy  in  all  re- 
spects.    For  a  week  or  more  all  went  well,  excepting  that 


CONGENITAL  DTSPEPSIA.  173 

frequently  after  nursing  there  would  be  some  vomiting,  accom- 
panied by  eructations  of  wind,  and  oftentimes  crying  as  if  from 
colic.  After  this  the  baby  cried  almost  incessantly,  unless  car- 
ried  in  the  arms ;  and  during  several  succeeding  months,  there 
was  but  little  peace  or  quiet  in  this  household.  When  the 
baby  was  about  two  weeks  old,  and  as  soon  as  it  manifested 
signs  that  something  was  wrong,  I  examined  the  mother's  milk 
carefully  and  repeatedly,  and  compared  it  with  the  milk  of  two 
other  women  who  were  confined  about  the  same  time.  It  was 
apparently  the  best  of  the  three  specimens. 

I  could  not  believe  that  the  milk  was  at  fault,  and  urged 
continued  nursing.  The  baby  continued,  however,  to  cry  and 
pine. 

The  mother  had  plenty  of  nourishment,  and  it  was  taken 
with  avidity.  The  bowels  were  not  especially  disturbed ;  vom- 
iting was  only  slight  and  occasional.  After  the  third  week  I 
yielded  my  judgment  to  that  of  the  parents,  and  commenced 
artificial  feeding — first  trying  a  wet-nurse  without  any  im- 
provement. 

The  history  of  the  succeeding  year,  if  complete,  would  fill  a 
fair-sized  volume.  I  tried  nearly  all  available  aliments  from 
cow's  milk,  fresh  and  condensed,  on  through  nearly  the  entire 
list  of  foods.  When  eight  months  old  the  baby's  condition 
was  indeed  pitiable.  She  was  but  little  larger  than  when  born. 
The  skin  of  the  legs,  arms  and  body  could  be  raised  in  folds ; 
that  of  the  face  was  wrinkled  and  old-looking — in  short,  I  had 
a  typical  case  of  marasmus,  with  all  that  the  name  implies. 
About  this  time,  cerebral  symptoms  set  in ;  such  as  starting  in 
sleep,  with  a  sharp,  shrill  cry — the  "  cri  encephalique  " — boring 
of  the  head  into  the  pillow ;  pupils  of  eyes  sometimes  dilated, 
and  again  contracted  ;  a  whining,  distressful  cry  was  almost 
continuous,  unless  kept  in  motion.  Thrush  showed  itself  in  the 
mouth  ;  and  extensive  erythema  about  the  arms  occurred  at  a 
somewhat  earlier  period,  and  both  were  more  or  less  obstinate. 
At  a  later  period  a  dropsical  condition,  which  was  more  or  less 
general,  was  manifested.  Edema  of  the  lower  extremities 
was  especially  marked,  and  serous  tumors  would  form  on  the 
head,  sometimes  closely  simulating  a  hydrocephaloid  condi- 
tion. All  of  these  intercurrent  symptoms  yielded  more  or  less 
readily  to  the  indicated  and  usual  remedies,  leaving  the  maras- 
matic  condition,  however,  but  little  improved.  Finally,  how- 
ever, after  exhausting  my  resources,  and  in  sheer  desperation,  I 
prepared  a  mixture  of  gelatine  and  arrowroot,  according  to  the 
formula  of  Meigs  and  Pepper.  Even  this  did  not  answer  until 
all  cream  was  substituted  for  milk  and  cream,  as  by  them 
directed.     In  this  case  there  was  a  complete  and  continuous 


174  THE  DISEASES  OF  CHILDREN. 

inability  to  digest  casein,  and  a  similar  inability  is  met  with 
not  infrequently. 

In  the  conduct  of  the  case,  injections  of  Valentine's  meat- 
juice  were  used,  as  well  as  daily  inunctions  of  olive  oil.  But 
with  all  my  efforts  to  support  nutrition,  and  in  spite  of  all  ex- 
pedients which  were  well-nigh  exhaustive,  it  was  not  until  the 
above  preparation  of  gelatine  and  arrowroot  was  used  that  I 
could  see  perceptible  improvement.  From  its  exhibition  the 
baby  commenced  to  gain,  very  slowly  but  surely,  and  has  con- 
tinued to  do  so  to  the  present  time.  At  this  writing — the  baby 
being  now  eighteen  months  old — her  condition  is  as  follows : 
She  has  six  teeth,  anterior  fontanel  unclosed,  but  closing  ;  ap- 
petite and  digestion  good  ;  sleeps  well ;  is  happy  and  playful ; 
creeps  about  the  floor,  but  cannot  stand  ;  she  is  small  in  size, 
but  her  appearance  is  natural  and  healthy,  and  her  face  has  lost 
all  trace  of  suffering  and  disease.  She  is  slowly  but  steadily 
growing  out  of  a  condition,  which  seemed  for  weeks  and  even 
months,  to  be  almost  hopeless. 

But  why  should  this  child  so  soon  after  birth — a  plump  and 
hearty  child  when  born — have  drifted  into  such  an  apparently 
hopeless  and  pitiable  condition  ? 

While  studying  the  case  I  elicited  the  following  facts,  which 
seemed  to  help  answer  the  question,  and  convinced  me  that 
heredity  had  much  to  do  with  it.  This  was  the  fifth  baby  born 
to  this  family.  The  first  one  weighed  thirteen  pounds  at  birth, 
showed  marked  indigestion  before  it  was  a  month  old,  and  died 
at  the  age  of  seven  months. 

The  second  weighed  ten  pounds  at  birth  ;  was  nursed  three 
weeks  ;  then  put  upon  artificial  food,  but  continued  to  decline, 
and  died  at  the  age  of  seven  weeks,  from  purging  and  vomiting. 

The  third  and  fourth  children  were  not  nursed  at  all,  but 
Harry  (the  fourth)  had  marasmus  dating  from  his  second 
month,  which  lasted  until  he  was  nearly  a  year  old.  The  third 
child,  now  eight  years  old,  has  frequent  attacks  of  indigestion 
accompanied  with  epileptoid  fits.  Both  of  them  are  under-sized 
and  cachectic. 

Mrs.  E.,  the  mother,  is  a  remarkably  strong  and  healthy 
woman  ;  says  she  has  never  had  a  sick  day  in  her  life.  Her 
father,  however,  was  dyspeptic,  and  she  has  three  aunts  who  are 
confirmed  dyspeptics. 

The  father  of  the  family  is  a  Virginian  by  birth ;  a  man  of 
splendid  physique,  standing  over  six  feet  in  his  stockings;  a 
man  of  large  appetite  and  larger  passions.  He  is  highly  edu- 
cated, being  a  civil  engineer  by  profession ;  has  traveled  the 
world  over  in  pursuit  of  business  or  pleasure,  and,  being  a 
thorough  gourmand,  has  had  indigestion  in  nearly  every  civil- 


CONGENITAL  DYSPEPSIA.  175 

ized  country  on  the  globe.  He  has  no  other  defect  of  organi- 
zation that  I  have  been  able  to  discover,  and  hence  the  question 
recurs,  why  have  these  parents,  who  in  a  general  way  are  so 
exceptionally  strong  and  vigorous,  had  such  a  succession  of 
puny  and  delicate  children  ?  I  cannot  help  the  conclusion 
that  the  abused  and  deranged  stomach  of  the  father  has  been 
transmitted  to  the  children,  reproducing  in  them  a  dyspeptic 
condition,  according  to  the  well-recognized  laws  of  heredity. 

Case  .?.— Mrs.  L.,  35  years  old  ;  weight  no  lbs  ;  height  5  feet 
6  inches;  married  13  years;  has  had  six  children  with  easy 
labor.  Last  child  born  August  6,  1881.  Baby  was  plump  and 
weighed  eight  pounds  when  two  weeks  old.  From  birth  had 
colic;  constipation,  alternating  with  diarrhea;  eructations  of 
wind  ;  vomiting  of  curdy  masses ;  stools  natural  enough  in 
color ;  fetid  diarrhea  for  three  days  before  death,  which  oc- 
curred at  end  of  eighth  week.  The  baby  did  not  grow  and 
increase  in  weight,  but  was  not  especially  emaciated.  Four 
of  the  other  children  died  in  the  same  manner  at  about  the 
same  age,  none  of  them  living  beyond  the  third  month,  although 
all  were  plump  and  well-nourished  at  birth.  The  fourth  child 
in  the  order  of  birth  and  the  one  living,  now  eight  years  old, 
has  a  very  delicate  stomach,  and  was  only  raised  thus  far 
by  dint  of  care.  She  was  wet-nursed  for  a  time,  as  was  the 
third  child,  which  died  at  the  age  of  six  weeks. 

This  woman's  mother  was  always  a  dyspeptic,  and  died  in 
middle  life  of  gradual  decline.  She  herself  has  had  chronic 
diarrhea  most  of  the  time  since  she  can  remember,  in  spite  of 
which  she  neither  looks  nor  acts  like  an  invalid.  By  carefully 
regulating  her  diet,  which  experience  has  taught  her  to  do,  she 
maintains  an  average  amount  of  vigor.  While  having  a  some- 
what delicate  look,  she  has  good  color,  skin  clear,  lips  red. 
Being  a  lady  of  rare  culture  and  somewhat  reduced  in  circum- 
stances, she  has  been  obliged  to  do  more  or  less  labor  of  a  kind 
that  has  taxed  her  mind  and  nervous  system,  and  she  thinks 
her  babies  have  died  from  participating  in  her  "  nervous  ex- 
haustion." That  this  is  not  so,  is  evidenced  from  the  fact  that 
so  long  as  her  children  share  her  blood  and  are  nourished  by 
her  direct,  they  are  well  and  strong,  and  are  born  red  and 
plump.  But  as  soon  as  they  are  thrown  on  their  own  re- 
sources, in  the  matter  of  digestion,  they  fail  to  thrive,  and 
speedily  perish.  None  of  them  ever  had  convulsions.  The 
father  of  this  family  claims  to  have  good  digestion.  He  is, 
however,  thin,  scrawny  and  undersized.  Morbus  coxalgia  in 
early  life  left  one  leg  shorter  than  the  other. 

In  both  the  cases  here  cited,  the  presumption  of  an  inherited 
defect  of  the  nutritive  function  is  certainly  probable  and  war- 


176  "  THE  DISEASES  OF  CHILDREN. 

ranted  by  logic  and  analogy.  That  function,  as  well  as  organi- 
zation, may  be  and  is  inherited  is  evidenced  by  volumes  of 
authenticated  facts. 

I  know  well  a  family  of  ten  grown  persons,  all  of  whom  have 
children  of  their  own.  In  three  generations  there  is  not  a  poor 
or  weak  stomach,  nor  is  indigestion  known  among  them.  Every 
member  of  the  family  from  grandparents  to  grandchildren  are 
hearty,  ruddy  and  strong,  and  all  are  good  feeders ;  but  ev^ery 
grown  member  of  this  family  has  defective  vision,  and  some  of 
them  have  worn  glasses  from  puberty. 

Zimmerman  cites  the  case  of  a  whole  family  upon  whom 
coffee  acted  as  opium  acts  on  others,  while  opium  had  no 
sensible  effect  whatever.  Sir  Henry  Holland  says  that  he 
knows  of  a  family  where  four  out  of  five  children,  otherwise 
healthy,  became  totally  blind  from  amaurosis  about  the  age 
of  twelve,  the  vision  having  been  gradually  impaired  up  to  this 
time. 

Indeed,  the  evidence  is  ample  to  show  that  we  inherit  from 
our  parents,  not  alone  the  general  form  and  features,  the  bony, 
muscular,  nervous  and  glandular  structures,  but  the  foibles,  the 
weaknesses,  susceptibilities  and  morbid  tendencies  as  well. 
But  I  do  not  propose  to  discuss  here  the  general  question  of 
disease  transmission,  nor  insist  upon  it  that  all  cases  of  defect- 
ive nutrition  in  the  infant  are  inherited;  but  I  do  maintain 
that  many,  if  not  most  of  them,  date  from  birth,  and  are  hence 
congenital. 

The  practical  and  all-important  deduction  from  these  prem- 
ises is  that  the  physician  who  has  to  treat  these  babies  must  be 
quick  to  realize  the  situation,  and  treat  them  accordingly.  No 
Procrustean  bed  will  answer  for  these  cases.  It  will  not  do 
here  to  force  unassimilable  food.  Their  weak  and  delicate 
stomachs  are  utterly  unable  to  appropriate  and  absorb  that 
which  is  generally  regarded  as  wholesome  and  nutritive.  What 
is  cibus  deoriint  to  a  healthy  babe  is  stercus  diaboli  to  such 
children  as  these. 

And  yet  these  cases  are  by  no  means  hopeless.  On  the  con- 
trary, a  careful  and  intelligent  selection  of  food,  a  judicious  but 
persistent  hygiene,  and  the  homeopathic  treatment  of  the 
symptoms  as  they  arise,  will  surprise  the  most  sanguine  and 
excite  the  wonder  of  those  who  are  disposed  to  be  skeptical. 

Diagnosis. — A  word  or  two  upon  the  diagnosis  and  treatment 
of  these  cases.  But  little  need  be  said  under  either  heading, 
but  that  little  may  be  important  to  the  junior  members  of  the 
profession. 

The  only  one  of  the  constitutional  diseases  which  is  likely  to 
be  mistaken  for  congenital  dyspepsia  is  tabes  mesenterica  ;  but 


CONGENITAL  Dl'SPEPSIA. 


177 


there   are    certain  distinctive  differences   which   will  be   very- 
apparent,  by  a  comparison  of  the  two  affections. 


TABES    MESENTERICA. 

Mesenteric  glands  always  hypertro- 

phied. 
Appetite  voracious. 
Stools  liquid,  putrid  and  corroding. 

Fever  intense  and  continuous. 
Greedy  thirst. 

Tympanitis  always  and  continuous. 
Commences  during  dentition. 
Atrophy  of  brain,  with  distortion  of 

calvaria. 
Great  debility  and  prostration. 
Dropsy  early  in  the  disease. 
Fatal  tendency. 
Emaciation  rapid. 


CONGENITAL    DYSPEPSIA. 

Mesenteric  glands  not  hypertro- 
phied. 

Appetite  variable. 

Stools  thin  and  frequent  but  not  pu- 
trid. 

No  continued  fever. 

Little  or  no  thirst. 

Tympanitis  occasional  and  transient. 

Prior  to  dentition. 

Head  preserves  its  normal  contour. 

Strength  well  maintained. 
Dropsy  late. 
Prognosis  hopeful. 
Emaciation  slow  and  gradual. 


Histological. — As  to  the  morbid  anatomy  of  this  affection, 
little  is  definitely  known.  Those  that  die  generally  perish 
from  some  intercurrent  complication  which  was  not  neces- 
sarily part  of  the  original  trouble. 

Primarily  there  is  only  one  morbid  condition :  a  functional 
deficiency,  a  lack  of  digestive  power.  The  peptic  glands  may 
be  sufficiently  matured,  but  they  are  inactive.  The  liver  may 
be  relatively  proportionate,  so  far  as  size  and  bulk  are  con- 
cerned, to  the  general  weight,  but  it  is  sluggish  and  inefficient. 
In  consequence  the  stools  are  white  or  grayish  and  papescent. 

That  a  congenital  feebleness  of  the  digestive  function,  such 
as  is  here  indicated,  may  exist  even  to  a  fatal  extent,  is  shown 
by  some  experiments  of  Claude  Bernard  on  the  lower  animals. 
He  says,  "  Experience  has  taught  us  that  patients  often  die 
without  offering  in  the  post-mortem,  examination  the  slightest 
modification  in  the  anatomical  condition  of  their  organs.  In 
the  course  of  our  physiological  experiments,  we  often  see  dogs 
arrive  at  the  very  last  stage  of  emaciation,  although  the 
appetite  continues  unimpaired  till  the  last  moment.  They  sink 
from  sheer  exhaustion,  while  the  lacteals  are  gorged  with 
chyle ;  and,  when  opened,  their  bodies  offer  no  trace  whatever 
of  pathological  alteration."* 

Treatment. — I  need  scarcely  say,  there  is  no  specific  for  this 
affection.  Each  case  will  show  peculiarities  which  will  require 
a  careful  study  of  remedies  and  render  a  selection  oftentimes 
dif^cult.  The  symptoms  alone  will  furnish  a  safe  guide.  At 
certain  stages  the  remedies  will  have  to  be  changed  frequently 


*  LecUire    on    Experimental    Physiology,  by    Claude   M.   Bernard,  Med.    Times  and 
Gazette.,  i860,  vol.  i,  page  209. 

D.  C— 12 


178  THE  DISEASES  OF  CHILDREN. 

to  meet  new  and  sometimes  unexpected  complications.  The 
treatment  must  always,  of  necessity,  be  largely  dietetic  and 
hygienic,  and  the  aliment  must  be  selected  with  reference  to 
the  capacity  of  the  given  case.  In  these  cases  rules  which 
should  govern  healthy  children,  must  be  ignored,  or  at  least 
held  in  abeyance.  In  the  selection  of  food,  it  will  often  be 
found  that  a  most  unpromising  food  for  a  well-bred  stomach 
will  be  just  the  thing  here,  e,  g.,  gelatine  and  arrowroot,  as  in 
the  case  before  cited. 

One  thing  must  not  be  forgotten.  These  children  cannot 
digest  casein  without  artificial  help.  Theoretically,  the 
addition  of  a  small  quantity  of  Hale's  comp.  digest,  or  lacto- 
peptine,  ought  to  aid  its  digestibility.  By  the  addition  of 
pepsin  in  some  form  the  nitrogenous  element  of  the  milk 
ought  to  be  sufficiently  peptonized  before  taken  into  the 
stomach  to  render  the  milk  perfectly  assimilable.  Practically ,^ 
my  experience  has  been  so  limited  with  these  "aids,"  that  I 
cannot  speak  authoritatively.  Cream,  either  clear  or  mixed 
with  Mellin's  food  and  made  very  dilute,  has  usually  served 
me  well,  and  has  proven  in  several  cases  the  only  food  for  the 
incipient  stage.  Cod-liver  oil,  in  emulsion  or  otherwise,  will 
often  prove  serviceable.  Inunctions  of  olive  oil,  cod-liver  oil 
or  the  more  elegant  preparation  known  as  the  "  unguentum 
graecorum,"  which  is  made  of  cocoa-butter  and  almond  oil,  is 
of  decided  advantage  and  should  be  used  daily.  The  oil  bath 
should  be  substituted  for  the  water  bath,  the  latter  being 
used  as  sparingly  as  possible. 

The  value  of  fresh  air  is  inestimable,  and  should  never  be 
forgotten.  Warmth  is  a  sine  qua  non  of  cure,  and  it  is  almost 
impossible  to  keep  these  children  too  warm.  Their  blood 
easily  chills,  and  they  require  to  be  kept  in  a  warmer  room,  and 
to  be  more  warmly  clad  than  their  more  robust  brothers  and 
sisters. 


CHAPTER   IV. 

DIARRHEA. 

Definition  and  Characteristics. — Diarrhea  is  one  of  the  most 
frequent  of  all  the  ailments  of  infancy  and  childhood.  By  the 
term  is  meant,  an  unusual  frequency  of  the  alvine  discharges 
with  more  or  less  change  in  their  peculiar  characteristics.  The 
normal  frequency  of  stools  in  a  healthy  infant  during  its  first 
month  should  be  from  three  to  four  in  the  twenty-four  hours. 
After  this  period  and  during  the  first  year,  the  daily  average  of 
stools  should  be  at  least  two  and  in  a  hearty  child  may  be 
double  this  number  without  any  cause  for  apprehension,  pro- 
vided the  character  of  the  stool  is  normal  and  the  system  does 
not  suffer  in  consequence. 

Immediately  after  birth  the  discharges  from  the  bowels  are 
dark-green  or  brown  or  even  black  in  color,  due  to  the  meco- 
nium. During  the  early  period  of  infancy,  the  discharges  are  of 
a  soft,  papescent  character,  light  yellow  in  color,  and  devoid  of 
fetor.  During  the  remainder  of  infancy,  they  are  still  soft,  more 
frequent  than  in  adult  life  and  yellow  or  of  light-brownish  hue. 
Normal  stools  in  infancy  are  homogeneous  in  character,  what- 
ever the  consistency  or  color. 

Light  gray  or  clay-colored  stools  denote  an  absence  of  bile 
and  may  indicate  hepatic  disease. 

In  chronic  diarrhea,  the  stools  are  thin,  dark-brown  and  intol- 
erably fetid.  Meat  juice,  especially  the  meat  extracts,  give 
to  the  stools  a  dark  color  and  great  fetor. 

The  dark-green  color  of  the  stools  is  due  to  bile,  which  is 
turned  green  by  the  acid  character  of  the  intestinal  secretions. 

Where  bright  blood  is  passed  in  the  stools  it  comes  from  the 
colon  ;  blood  from  the  ileum  is  turned  brown  before  being  dis- 
charged. 

Frothy  acid  discharges  from  the  bowels,  of  a  light  yellow  or 
slightly  green  color,  indicate  a  disturbance  of  the  digestive 
functions  ;  generally  from  overfeeding  or  improper  food. 

Discharges  of  slimy  mucus  occur  in  irritations  of  the  bowels, 
from  worms  or  teething ;  or  they  are  the  consequence  of  an 
increase  of  the  mucus  exhalation  of  the  follicles  of  the  intes- 
tines, caused  by  the  impression  of  cold  upon  the  surface. 

Repeated  discharges  of  viscid  mucus,  occasionally  streaked 

(179) 


180  THE  DISEASES  OF  CHILDREN. 

with  blood,  or  of  a  greenish  fluid,  mixed  with  small  masses 
resembling  the  curd  of  milk,  are  frequent  in  most  of  the  inflam- 
matory affections  of  the  bowels. 

A  deep-green  color  of  the  stools,  the  discharges  resembling 
chopped  grass  or  spinach,  is  generally  a  symptom  of  serious 
disease  of  the  stomach  or  intestines ;  and  is  a  striking  feature 
of  acute  gastritis,  and  the  more  acute  grades  of  gastro-intestinal 
inflammations. 

A  diminution  in  the  number  of  stools,  when  diarrhea  occurs 
as  a  symptom  of  disease  in  children,  with  a  return  to  the  ordi- 
nary healthy  condition  in  the  color  and  consistence  of  the  dis- 
charges, is  a  favorable  symptom.  So,  also,  is  the  appearance  of 
natural  feces  in  cases  of  dysentery,  and  of  bile  in  the  discharges 
in  cholera  infantum. 

The  passage  from  the  bowels  of  the  substances  taken  as  food 
entirely  unchanged,  or  but  little  altered,  constitutes  a  condition 
called  lienteria,  and  indicates  excessive  irritability  of  the  ali- 
mentary canal.  It  occurs  in  inflammation  of  the  stomach  and 
bowels,  but  more  frequently  in  protracted  cases  of  cholera  in- 
fantum and  chronic  diarrhea. 

Diarrhea  in  children  does  not  always  indicate  disease,  nor 
does  it  always  call  for  medicinal  treatment.  When  irritating 
substances  have  been  taken  into  the  stomach,  which  are  not 
nutritious  and  cannot  be  made  useful  in  the  economy,  nature 
seeks  to  rid  herself  of  the  foreign  substance,  either  by  vomiting 
or  a  salutary  diarrhea.  In  either  case,  it  would  be  folly  to  in- 
terfere with  the  process,  since  no  possible  good  could  be  ac- 
complished by  so  doing.  But  it  often  happens  that  the  diar- 
rhea, which  was  salutary  in  the  beginning,  continues  even  after 
the  end  is  accomplished  from  the  irritation  thus  set  up,  and 
needs  to  be  controlled  before  serious,  or  at  least,  unnecessary 
loss  of  strength  is  occasioned. 

Some  writers  divide  this  subject  of  diarrhea  into  a  great 
number  of  varieties,  basing  the  division  upon  the  location  of 
the  pathological  lesion,  or  its  supposed  location,  and  again 
multiplying  terms  according  to  the  real  or  fancied  condition 
causing  the  diarrhea.  These  pathological  names  are  in  our  judg- 
ment a  hindrance  rather  than  a  benefit,  since  nothing  short  of  a 
post-mortem  investigation  can  determine  in  a  given  case,  whether 
the  exact  seat  of  the  lesion  is  in  the  upper,  lower,  or  middle  third 
of  the  ileum,  or  an  inch  beyond  its  junction  with  the  colon.  The 
division  of  diarrheas  into  bilious,  mucous  and  serous  has  a  bet- 
ter recommendation ;  but  this  is  more  theoretical  than  practi- 
cal, since  the  discharges  rarely  maintain  for  a  length  of  time 
the  characteristics  with  which  they  began.  In  order  to  avoid 
prolixity  and  retain  sufficient  accuracy  of  description  for  all 


SIMPLE  DIARRHEA.  181 

practical  purposes,  we  shall  consider  all  forms  of  diarrhea  under 
the  following  heads,  viz.:  Simple,  or  non-inflammatory  diarrhea ; 
entero-colitis,  or  inflammatory  diarrhea  ;  cholerine,  or  cholera 
infantum,  and  hemorrhagic  diarrhea,  or  dysentery. 

Simple  Diarrhea  —  Z>^/«i/?o«.  —  This  is  the  most  fre- 
quent form  of  diarrhea  encountered  in  infancy  and  childhood. 
It  is  non-inflammatory  in  character,  but  if  its  producing  cause 
be  not  arrested,  it  may  lead  to  a  catarrh  of  the  bowels  or  to 
inflammation  (entero-colitis).  Its  duration  is  variable.  It  may 
last  but  a  few  hours,  and  then  cease  spontaneously,  or  the 
evacuations  may  occur  every  few  minutes  and  continue  with 
little  or  no  abatement  for  a  considerable  length  of  time,  ex- 
hausting the  strength  of  the  patient  and  producing  extreme 
emaciation. 

Causes. — The  causes  which  may  give  rise  to  this  form  of 
diarrhea  are  innumerable.  Anything  which  disturbs  the  func- 
tion of  alimentation,  in  the  way  of  food  which  is  not  assimila- 
ble, or  which  disorders  the  nervous  system  so  as  to  lower  the 
tone  of  the  digestive  apparatus ;  anything  which  checks  the 
cutaneous  transpiration  and  thus  congests  the  mucous  mem- 
brane ;  anything  which  disturbs  the  equilibrium  of  the  circula- 
tion ;  any  or  all  of  these  influences  may  give  rise  to  simple 
diarrhea.  Probably  the  most  prolific  causes  are  acrid  or  irritat- 
ing food,  and  the  influence  of  cold.  The  use  of  farinaceous  food 
at  too  early  an  age,  when  the  digestive  powers  of  the  infant  are 
unequal  to  the  task  of  effecting  the  necessary  changes  in  it  to 
render  it  assimilable,  has  already  been  spoken  of  and  its  dan- 
gers pointed  out.  Other  articles  of  food  are  perhaps  equally 
injurious.  The  unhealthy  state  of  the  nurse's  milk  is  another 
cause  of  frequent  occurrence.  The  indiscriminate  diet  allowed 
after  an  infant  is  weaned  is  a  fruitful  source  of  gastric  and  in- 
testinal complaints.  So  also  is  the  effect  of  cold  and  wet  ap- 
plied to  the  surface  of  the  body,  and  still  more,  the  sudden 
transition  from  a  heated  to  a  chilly  atmosphere.  The  effect  is 
to  constringe  the  skin,  and  direct  the  course  of  the  blood  to 
the  internal  surfaces,  where  it  first  produces  engorgement  of 
the  vessels  and  then  a  relaxation  of  them.  Insufficient  cloth- 
ing, especially  in  our  changeable  northern  climate,  is  responsi- 
ble for  many  a  diarrhea  of  more  or  less  serious  character. 
Infants  who  are  carelessly  allowed  to  become  uncovered  at 
night  after  the  fires  have  gone  down  are  very  liable  to  bowel 
complaint.  Extreme  heat,  if  much  prolonged,  is  a  well- 
known  cause  of  diarrhea.  Its  effect  is  to  relax  the  system 
and  produce  an  enervated  condition  at  variance  with  the 
demands  of  complete  digestion.     Certain  foods,  too,  are  espe- 


182  THE  DISEASES  OF  CHILDREN. 

cially  liable  to  fermentative  changes  in  hot  weather,  and  if 
taken  into  the  stomach  quickly  produce  disorder  there  or 
in  the  intestinal  tract  below.  The  influence  of  dentition  in 
this  connection  will  be  treated  subsequently  under  its  appro- 
priate head. 

Histological. — Simple  diarrhea  is  a  purely  functional  phe- 
nomenon, and  therefore  is  not  accompanied  by  any  structural 
or  anatomical  change,  unless  tumefacation  of  intestinal  follicles 
may  be  so  regarded.  There  may  be  in  these  cases  some  dimin- 
ished firmness  of  the  mucous  membrane,  and  more  or  less 
swelling  of  the  glands  of  Peyer,  but  no  lesions  characteristic  of 
inflammation.  Niemeyer — and  others  also — describe  all  forms 
of  diarrhea,  even  the  mildest,  under  the  term  "  catarrhal  inflam- 
mation," and  consider  even  the  transient  effects  of  a  purgative 
as  an  incipient  catarrh.  But  it  seems  much  more  rational  to  re- 
gard those  diarrheas,  which  immediately  abate  with  the  removal 
of  the  cause  and  which  are  unattended  by  marked  anatomical 
change,  as  non-inflammatory. 

Symptoms. — Simple  diarrhea  may  come  on  suddenly  and  with- 
out precursory  symptoms  or  indications  of  gastric  uneasiness, 
or  symptoms  of  indigestion  may  precede  for  a  day  or  two. 
When  these  prodromic  symptoms  are  present  they  are  ill  defined 
and  are  mainly  restlessness,  disturbed  sleep,  transient  abdom- 
inal pains,  loss  of  appetite  and  perhaps  nausea  or  vomiting. 
The  stools  vary  greatly,  both  in  color  and  character.  In  young 
infants  they  are  apt  to  be  green,  even  when  the  cause  is  most 
trivial.  If  the  diarrhea  occurs  in  a  nursing  infant  or  one  who 
is  bottle-fed,  particles  of  coagulated  casein  are  apt  to  be  scat- 
tered through  the  stool.  If  the  stools  are  acid  in  their  reaction 
or  to  any  extent  irritating,  there  may  be  more  or  less  tenesmus. 
The  frequency  of  stools  diminishes  during  the  night,  for  the 
reason  that  food  and  drink  are  then  suspended.  In  mild  attacks 
there  is  but  little  thirst,  but  if  the  stools  are  frequent  and 
copious,  the  thirst  may  be  great.  The  tongue  is  moist.  There 
may  be  some  meteorism,  but  no  abdominal  tenderness.  The 
loss  of  weight  and  firmness  of  flesh  which  may  follow  or  result 
from  a  simple  diarrhea  in  a  brief  space  of  time  is  amazing.  A 
few  days  may  suffice  to  lose  the  rotundity  of  limbs  and  render 
the  tissues  soft  and  flabby.  The  great  danger  in  simple,  non- 
inflammatory diarrhea  arises  from  the  fact  that  it  may  speedily 
and  imperceptibly  take  on  an  inflammatory  form,  or  if  the 
season  be  favorable,  that  more  serious  one  still — cholera  infan- 
tum. In  mild  cases  the  stools  do  not  altogether  lose  their 
feculent  character,  but  are  more  frequent,  copious  and  thinner, 
and  the  odor  becomes  pungent  and  offensive. 

Prognosis. — So  long  as  the  diarrhea  remains  simple  the  prog- 


INFLAMMA  TOR T  DIA RRHEA.  183 

nosis  is  favorable,  even  thoug[h  the  emaciation  be  considerable 
and  the  disease  prolonged.  During  the  heat  of  summer  there 
is  more  danger  than  when  the  weather  is  cool,  and  always  more 
danger  in  city  than  in  country. 

The  greatest  danger  arising  from  simple  diarrhea,  is  from 
exhaustion.  The  drain  upon  the  fluids  of  the  body  and  the 
consequent  exhaustion  may  produce  such  a  condition  of  debil- 
ity as  to  affect  the  brain  and  cause  spurious  hydrocephalus. 
The  physician  should  always  be  on  his  guard  in  severe  cases  of 
diarrhea  lest  the  exhaustion  resulting  therefrom  be  more  pro- 
found than  he  is  aware  of.  The  cessation  of  the  discharges  is 
not  always  a  good  omen.  It  may  be  due  to  such  a  state  of 
■enervation  that  the  secretory  function  of  the  intestines  is  sus- 
pended, or  to  a  failure  of  the  peristaltic  movements  of  the 
bowels.  We  can  never  be  sure  that  all  danger  is  past,  until 
amendment  has  been  maintained  for  a  day,  and  normal  stools 
have  appeared. 

Treatment. — In  order  to  avoid  needless  repetition  we  shall 
treat  all  the  forms  of  diarrhea  together  at  the  close  of  the 
chapter. 

Inflammatory  Diarrhea. — (Entero-colitis ;  Febrile  Diar- 
rhea ;  Intestinal  Catarrh.) 

Definition. — Under  this  head  we  propose  to  treat  of  that 
form  of  diarrhea  which  is  attended  with  fever  and  other 
symptoms  of  intestinal  inflammation,  whether  it  be  situ- 
ated in  the  ileum,  the  colon,  or,  as  is  commonly  the  case, 
in  both. 

We  have  already  referred  to  the  difficulty  of  locating  with 
any  exactitude  the  precise  seat  of  the  intestinal  lesion  in  these 
cases,  and  writers  generally  are  free  to  admit  that  there  is  no 
special  difference  in  the  symptoms  by  which  one  can  tell,  in  a 
given  case,  whether  the  inflammation  is  in  the  small  or  the  large 
bowel.  Billard,  who  is  conceded  to  be  one  of  the  closest  of 
observers,  after  analyzing  eighty  cases  of  intestinal  inflamma- 
tion in  infants,  says:  "  In  consequence  of  the  impossibility  we 
have  found  to  exist  of  tracing  with  exactitude  the  series  of 
symptoms  proper  to  inflammation  of  the  different  portions  of 
the  digestive  tube,  we  shall  content  ourselves  with  presenting 
an  analytical  sketch  of  the  causes,  symptoms,  and  ordinary 
course  of  inflammation  of  the  mucous  membrane  of  the  intes- 
tines in  general." 

In  using  either  of  the  above  terms,  therefore,  we  shall  intend 
to  refer  to  an  inflammatory  condition  of  the  bowels,  without 
special  reference  to  its  exact  locality,  or  whether  the  inflam- 
matory process  be  extensive  or  limited. 


184 


THE  DISEASES  OF  CHILDREN. 


COMPARATIVE  MORTALITY  OF  DIARRHEAL  DISEASES  BY  QUAR- 
TERS FOR  EIGHT  YEARS,  FROM  1 88$  TO  1 892  INCLUSIVE. 


Quarters. 

1885. 

1886. 

1887. 

188S. 

1889. 

1890. 

1891. 

1S92. 

Total 

for 
Quar- 
ters, 

Spring 

Summer 

Autumn 

Winter 

187 

861 

65 

35 

162 

841 

88 

43 

233 
1036 

79 

129 
1018 

71 
38 

88 
1350 

29 

177 

12S4 

105 

151 

350 

1286 

218 

141 

262 

1347 

145 

"3 

is88 

8923 

914 

629 

Totals  by  yrs. 

1148 

"34 

1419 

1256 

1618 

1717 

1995 

1867 

12054 

MORTALITY,   BY   MONTHS,    FOR   YEAR    1 892. 


Month. 


January... . 
February. . 

March 

April 

May 

Tune 

July 

August. . . . 
September 
October  . . . 
November. 
December  , 

Total.  .  . 


Cholera 
Infantum. 


26 

8 

9 

22 

25 
98 

444 
360 

155 
42 

13 
9 


Cause  of  Death. 


Dysentery. 


II 

6 

4 
2 

3 


54 


Entero- 
colitis. 


13 

9 
6 
21 
17 
34 
62 

84 
46 

13 
10 


326 


Simple 
Diarrhea. 


19 

5 
3 
II 
10 
9 
47 
49 
35 
21 

9 

5 


223 


Etiology. — It  seems  unnecessary  to  repeat  again  what  has 
been  said  in  a  previous  section  regarding  the  causative  influences 
that  are  a  constant  menace  to  the  lives  of  infants  and  children, 
especially  those  who  live  in  our  large  cities.  What  is  there 
said  of  the  causes  of  simple  diarrhea  is  equally  true  of  that 
inflammatory  form  which  we  are  now  considering.  There  are 
some  lessons  to  be  drawn,  however,  from  the  foregoing  tables 
of  statistics  which  ought  to  be  impressed  upon  the  reader.  The 
great  mortality  from  diarrheal  diseases  during  the  months  of 
June,  July  and  August  would  naturally  lead  one  to  infer  that 


I  NFL  A  MM  A  TOR  T  D  I A  RRHEA .  185 

the  heat  of  summer  was  the  principal,  if  not  the  only  factor  in- 
volved, and  that  the  greater  the  elevation  of  temperature  in  a 
given  year,  the  greater  the  consequent  mortality.  This  is  only 
partially  true.  If  it  were  wholly  so,  we  should  expect  to  find 
the  relative  mortality  just  as  great  in  proportion  in  the  smaller 
towns  and  in  the  open  country  as  in  the  wards  of  a  great  city. 
But  this  is  not  borne  out  by  the  facts. 

Entero-colitis  is  by  no  means  as  prevalent  proportionally  to 
population  in  the  former  as  in  the  latter.  Indeed,  it  is  com- 
paratively rare  for  a  child  to  die  of  summer  complaint  in  the 
country,  although  the  difference  in  temperature  between  it  and 
the  city  may  be  but  little.  There  is  manifestly  another  factor 
which  has  a  greater  influence  than  mere  heat,  and  this  factor  is 
a  sanitary  one. 

In  the  large  cities  the  population  is  overcrowded,  and  the 
poorer  classes  live  in  cellars  that  are  damp,  and  alleys  that  are  reek- 
ing with  filth.  Besides  this,  the  food  supply  is  stale  and  al- 
ready undergoing  incipient  decomposition  before  it  reaches  the 
consumer ;  and  here  we  have  the  real  cause  of  the  terrible  mor- 
tality that  gives  the  urban  infant  less  than  one  chance  in  two  to 
see  its  fifth  birthday.  In  Paris,  where  the  streets  are  kept  clean 
both  summer  and  winter,  and  where  overcrowding  is  forbidden 
by  law,  where  all  food  is  inspected  before  it  is  distributed,  there 
is  no  such  mortality  as  we  have  in  this  country  and  England. 
A  lady  once  told  me  that  she  was  going  to  Paris  soon  where 
her  parents  resided,  in  order  that  her  babe  might  escape  the 
perils  of  its  second  summer.  "Because,  you  know,"  she  said, 
"  in  Paris  babies  do  not  have  any  '  second  summer.'  "  In  the 
Foundlings'  Home  in  this  city  nearly  every  bottle-fed  infant  dies 
before  the  summer  is  over.  But  such  facts  as  these  are  too 
well  known  to  require  discussion.  In  this  city,  every  summer, 
as  soon  as  the  warm  weather  begins,  through  the  munificent 
bounty  of  my  friend,  Mr.  Victor  F.  Lawson,  proprietor  of  the 
Chicago  Daily  News,  a  sanitarium  is  opened  on  the  lake  shore, 
opposite  Lincoln  Park,  where  infants  and  children  are  brought 
from  all  over  the  city,  and  permitted  to  remain  there  through- 
out the  day,  enjoying  the  lake  breezes  from  morning  till  night, 
as  well  as  a  ride  on  the  open  water  on  steamers  that  transport 
them  back  and  forth.  While  at  the  sanitarium  they  are  sup- 
plied with  fresh  milk  and  other  foods,  the  best  the  market  af- 
fords. In  this  way  the  lives  of  scores,  if  not  hundreds,  of  chil- 
dren are  saved  every  summer.  I  have  repeatedly  seen  the  good 
effects,  in  my  private  practice,  of  sending  infants,  affected  with 
diarrhea,  on  the  water  for  a  daily  trip.  The  value  of  fresh  air 
and  the  cool,  uncontaminated  atmosphere  of  the  lake  is  quickly 
apparent. 


186  THE  DISEASES  OF  CHILDREN. 

The  great  difficulty,  which  almost  amounts  to  an  impossibil- 
ity, of  obtaining  cow's  milk  in  the  city  before  it  has  undergone 
more  or  less  decomposition,  has  induced  me  of  late  years  to 
advise  mothers  to  use  only  condensed  milk  during  the  summer 
months.  I  have  seen  a  material  abatement  of  bowel  troubles 
since  I  have  done  so. 

But  no  preparation  of  milk  or  other  food  compares,  for  very 
young  infants,  with  breast  milk,  and  this  should  always  be 
secured,  if  possible,  for  those  under  nine  or  ten  months  of  age. 

Symptoms. — The  inflammatory  diarrhea  of  infancy  commonly 
commences  with  a  slight  febrile  movement,  with  restlessness 
and  languor  and  a  diarrhea  so  mild  as  scarcely  to  attract  atten- 
tion. The  stools,  while  thinner  than  usual  and  somewhat 
more  frequent,  vary  greatly  in  appearance,  being  at  first 
yellow,  brown  or  green. 

The  tongue  in  the  commencement  of  the  attack  is  usually 
moist,  but  as  the  disease  advances  it  becomes  more  dry  and  is 
covered  with  a  light  fur.  Vomiting  is  common,  especially  in 
severe  cases.  In  sub-acute  cases  the  stools  are  not  very 
frequent,  numbering  not  over  four  or  five  in  twenty-four 
hours ;  but  they  have  a  very  bad  odor  and  contain  mucus  and 
undigested  food.  The  food  remains  depend  of  course  on  the 
diet.  If  this  is  milk  principally,  white  masses  of  fat  and 
occasional  particles  of  curd  are  constant.  If  the  food  consists 
of  oat-meal,  rice  or  barley,  these  cereals  can  be  readily 
detected  in  the  stools  with  the  naked  eye.  If  only  broths, 
peptones  and  other  pre-digested  foods  are  given,  the  stools  may 
consist  almost  entirely  of  intestinal  secretions,  mucus,  bile  and 
epithelium  cells.  The  most  constant  feature  of  these  stools  is 
glairy  mucus,  stained  with  bile  and  mixed  with  fecal  masses 
and  undigested  food.  Fresh  blood  is  rarely  seen,  except 
occasionally  in  the  beginning  of  the  attack,  and  then  is  due 
rather  to  congestion  than  ulceration.  In  severe  or  acute  cases 
the  number  of  stools  may  be  as  high  as  twenty  or  thirty  in 
twenty-four  hours  ;  but  the  larger  proportion  of  them  is  usually 
small  in  amount,  being  often  only  a  little  mucus,  or  mucus 
streaked  with  blood.  The  frequency  of  the  stools  is  greater 
during  the  day  than  night.  After  the  disease  has  lasted  for  a 
time,  the  moist  tongue  becomes  dry  and  parched  and  the  lips 
crack  and  bleed.  All  varieties  of  stomatitis  are  liable  to  be 
present  in  these  cases,  but  thrush  is  by  far  the  most  common. 
In  some  cases  the  stools  are  quite  uniform  in  appearance 
throughout  the  disease,  but  more  often  they  are  variable,  no 
two  of  them  being  alike.  The  skin  is  usually  dry  and  the 
quantity  of  urine  is  diminished.  In  protracted  cases  the  acrid 
character  of  the  stools  excoriates  the  nates,  and  produces  an 


I  NFL  A  MM  A  TOR  T  DIARRHEA .  187 

erythema  which  may  extend  down  and  around  the  thighs  and 
lower  part  of  the  abdomen.  Boils  on  the  forehead  and  scalp 
are  common  and  troublesome. 

On  account  of  the  enfeebled  circulation,  hypostatic  pneu- 
monia is  common,  affecting  usually  the  posterior  and  inferior 
portions  of  the  lobes  and  extending  but  a  little  way  into  the 
lungs.  The  only  prominent  symptom  of  hypostatic  pneumonia 
being  present,  according  to  Dr.  J.  Lewis  Smith,  is  an  occasional 
cough.  Limited  to  a  small  and  almost  immovable  portion  of 
the  lung,  it  does  not  ordinarily  accelerate  respiration  or  render 
it  painful,  and  the  cough  is  also  apparently  painless. 

Diagnosis. — As  already  stated,  the  symptoms  do  not  always 
indicate  the  precise  locality  in  the  bowels  which  is  the  seat  of 
the  inflammation,  but  post-mortem  investigations  show  that 
in  the  vast  majority  of  cases  the  lesion  is  either  in  the  lower 
portion  of  the  ileum  or  in  the  colon.  The  presence  in  the 
stools  of  glairy  mucus,  or  of  mucus  tinged  with  blood,  is 
pretty  good  evidence  that  the  colon  is  principally  involved. 
There  is  usually  but  little  abdominal  tenderness,  and  pain  is 
either  absent  or  causes  but  little  complaint.  Its  presence  or 
absence  is  no  aid  in  diagnosis.  The  frequency  of  the  stools 
and  their  admixture  with  mucus  and  blood  ;  the  presence  of 
fever  and  vomiting ;  the  attendant  prostration ;  the  gradual 
approach  of  serious  symptoms,  and  the  symptoms  of  indiges- 
tion which  generally  precede  the  bowel  trouble  by  several 
days,  are  sufficient  ordinarily  to  enable  one  to  make  a  correct 
diagnosis. 

Progfwsis. — Entero-colitis  is  always  a  serious  disease,  but  not 
by  any  means  a  necessarily  fatal  one.  Many  cases  are  met 
with,  characterized  by  some  gastro-intestinal  symptoms,  vomit- 
ing, high  temperature,  diarrhea,  and  nervous  manifestations, 
which  are  convalescent  in  a  few  days,  and  make  a  quick  and 
complete  recovery.  Other  cases,  and  these  are  in  the  majority, 
drag  along  for  an  indefinite  period  and  terminate  after  weeks 
or  months,  either  fatally  from  exhaustion  or  from  some  compli- 
cation, or  make  a  slow  or  tedious  recovery,  after  weeks  or 
months  of  tardy  convalescence.  If  the  inflammatory  condition 
results  in  follicular  ulceration,  the  chances  of  recovery  are 
very  small.  The  diagnosis  of  follicular  ulcers  is  difficult,  and 
can  only  be  made  from  taking  the  case  as  a  whole.  "  If  a  deli- 
cate infant,  which  from  time  to  time  has  been  specially  prone 
to  diarrheal  attacks,  especially  if  it  has  had  symptoms  of  a  mild 
catarrh  of  the  colon,  has  an  attack  which  starts  in  with  green 
mucus  stools,  and  which  continues  with  unabated  severity  for 
a  week  or  ten  days,  with  low  fever,  we  think  of  acute  follicular 
inflammation  as  certain  and  of  ulceration  as  probable.     If  these 


188  THE  DISEASES  OF  CHILDREN. 

symptoms  continue  for  weeks  without  intermission,  the  child 
all  the  time  failing  steadily  in  strength,  the  probability  becomes 
almost  a  certainty. 

"  If,  on  the  contrary,  after  three  or  four  days  of  acute  symp- 
toms, there  is  improvement  in  the  stools,  and  one  occasionally 
quite  fecal  in  character,  and  if  after  a  few  days  another  such 
exacerbation  occurs,  succeeded  by  another  remission,  and  so  on, 
we  may  be  tolerably  sure  that  no  ulcers  have  yet  formed." — 
L.  Emmet  Holt,  M.  D. 

In  cases  of  follicular  ulceration,  the  temperature  is  apt  to 
run  comparatively  low,  the  stomach  is  but  little  disturbed,  and 
the  course  of  the  disease  is  slow  and  irregular. 

The  greatest  danger  in  these  cases  arises  from  complication. 
During  the  hot  months  there  is  danger  from  cholera  infantum, 
as  a  sequela.  At  any  season  of  the  year,  there  is  constant  dan- 
ger of  serous  effusion  taking  place  into  the  encephalon,  pro- 
ducing spurious  hydrocephalus.  When  this  occurs  or  is 
threatened,  there  is  soper  alternating  with'extreme  restlessness 
and  a  return  of  vomiting.  Emesis  occurring  at  a  late  stage  of 
infantile  diarrhea  is  always  a  bad  prognostic  sign. 

Treatment. — The  successful  treatment  of  these  cases  necessi- 
tates a  thorough  knowledge  of  the  producing  causes,  and  the 
ability  to  improve  the  hygienic  environment.  A  change  of  air 
from  city  to  country  is  oftentimes  a  sine  qua  non  of  cure.  These 
children  must  have  plenty  of  fresh,  pure  air.  If  this  can  be  had 
at  home,  well  and  good;  but  if  not,  no  time  should  be  lost  in 
seeking  the  country. 

If  the  baby  is  but  a  few  months  old  and  is  being  hand-fed,  or 
if  it  has  just  been  weaned,  a  return  to  the  breast,  if  only  tem- 
porarily, may  be  imperative.  Where  this  is  impracticable,  some 
one  of  the  "  baby  foods,"  either  domestic  or  commercial,  will 
have  to  be  tried.  All  milk  should  be  boiled  and  peptonized, 
so  as  to  get  rid  of  all  curds.  Barley-water  will  be  found  very 
useful  with  young  infants.  Raw-meat  juice  must  not  be  for- 
gotten. 

As  there  is  usually  more  or  less  thirst,  fluids  are  eagerly 
taken,  and  with  a  little  care  the  drink  can  be  made  nutritious 
as  well  as  satisfying  to  the  thirst.  Toast-water  and  the  bread 
jelly  spoken  of  on  page  56  are  good.  As  the  appetite  is  slight 
and  precarious,  a  frequent  change  in  aliment  is  required.  Milk, 
if  properly  prepared  and  fresh,  is  all  right,  if  it  can  be  digested. 
Children  over  a  year  oJd  often  take  koumiss  with  avadity,  and 
there  is  no  milk  preparation  so  easily  digested.  It  satisfies 
thirst  while  affording  much  nutriment. 

If  the  measures,  already  prescribed,  fail,  we  may  still  find  a 
successful  pabulum  in  the  yolk  of  a  hard-boiled  egg — boiled  so 


I  NFL  A  MM  A  TOR  T  DIA  RRHEA .  189 

long  that  the  yolk  is  mealy — or  wine  whey,  of  which  the  child 
may  take  considerable  quantities  without  detriment.  Dr.  Meigs 
advises,  in  some  cases,  the  white  of  an  egg  stirred  in  a  small 
glass  of  water,  which,  he  says,  the  child  will  usually  drink  with- 
out recognizing  the  presence  of  the  albumen,  "and  we  are  thus 
enabled  to  administer  a  considerable  amount  of  nutritious  food, 
by  giving  the  whites  of  two  or  three  eggs  in  the  course  of  the 
day." 

Great  care  must  be  taken,  even  during  convalescence,  not 
to  overtax  the  digestive  powers. 

The  rule  for  feeding  should  be  *'  little  and  often,"  rather  than 
much  at  a  time. 

Local  measures  are  of  very  great  value  in  these  cases,  and 
should  never  be  neglected.  The  main  seat  of  the  inflammation 
is,  as  we  have  seen,  more  often  than  otherwise,  in  the  colon 
and  in  the  lower  half  of  it,  sometimes  being  confined  to  the  sig- 
moid flexure.  When  this  is  the  case,  nothing  but  good  can 
come  from  flushing  out  the  bowels  with  hot  water,  containing 
some  soothing  alkali,  such  as  borax.  It  cleanses  the  gut  of  all 
offending  matter,  soothes  the  irritation  of  the  mucous  membrane, 
and  acts  as  an  astringent  to  the  congested  circulation.  When 
used  for  their  local  effect,  the  enemata  may  consist  of  from  two 
to  four  ounces  of  water  as  hot  as  can  be  well  borne,  into  which 
has  been  dissolved  a  third  of  a  teaspoonful  of  powdered  borax. 
This  may  be  given  once  or  twice  daily  or  even  oftener.  Where 
the  inflammation  is  high  up  in  the  colon,  the  whole  viscus  may 
be  irrigated.  This  is  accomplished  by  inserting  a  large-sized 
flexible  catheter  or  rubber  rectal  tube  and  carrying  it  through 
and  beyond  the  sigmoid  flexure,  so  as  to  reach  as  near  as  possi- 
ble the  ileo-cecal  valve.  In  this  way  the  whole  colon  can  be 
flushed.  At  least  a  gallon  of  water  is  necessary,  into  which 
half  an  ounce  of  borax  should  be  dissolved.  Hamamelis  (witch 
hazel)  may  be  used  to  advantage  in  some  cases  instead  of  borax, 
especially  when  there  is  either  fresh  blood  in  the  stools  or  when 
the  discharges  contain  considerable  quantities  of  inspissated 
mucus.  The  hamamelis  may  be  used  in  the  proportion  of  one 
part  to  eight  of  water.  A  large-barreled,  hard-rubber  syringe 
may  be  used  to  force  the  injection,  or,  still  better,  a  fountain 
syringe,  the  bag  of  which  should  be  held  a  few  feet  above  the 
patient.  When  irrigation  is  used,  once  a  day  is  often  enough 
to  repeat  it. 

Moist  and  hot  applications  to  the  exterior  of  the  abdomen 
are  also  useful.  These  may  be  applied  in  the  form  of  fomenta- 
tions, /.  e.,  cloths  wrung  out  of  hot  water  and  covered  with 
oiled-silk  or  rubber  cloth,  or  in  the  form  of  a  poultice  made 
with  ground  flaxseed  stirred  up  with  boiling  water.     The  poul- 


b 


190  THE  DISEASES  OF  CHILDREN. 

tice  should  be  spread  on  cheese-cloth  and  applied  as  hot  as 
can  be  borne  without  discomfort.  When  cool  it  should  be  re- 
newed. These  measures,  simple  as  they  are,  are  of  great  bene- 
fit and  are  indorsed  by  the  highest  authorities  both  of  Europe 
and  this  country. 

Medicinal  Treatment. — There  is  scarcely  any  other  affection 
that  requires  such  close  discrimination  as  this  in  the  selection 
of  the  appropriate  remedies.  The  disease  itself  is  inclined  to  be 
kaleidoscopic.  Its  features  are  subject  to  frequent  changes, 
while  the  stools  are  of  almost  infinite  variety.  There  are, 
however,  associated  symptoms,  which,  taken  together — and 
they  must  be  so  taken — give  one  a  picture  of  the  remedy,  if  we 
take  the  trouble  to  go  deep  enough  into  their  differential  sig- 
nificance. There  is  no  specific  for  this  affection,  and  rarely  a 
single  remedy  that  will  cover  the  totality  of  the  symptoms. 
The  character  of  the  stool  is  but  one  of  the  many  guides  to  the 
selection  of  a  drug  in  a  given  case  ;  every  trifling  element  which 
goes  to  make  up  this  character  should  be  studied — the  color, 
odor,  form,  consistency,  frequency,  are  all  of  them  important. 
Then  the  mental  condition  of  the  patient  should  be  consid- 
ered, whether  apathetic  or  irritable ;  the  general  state,  whether 
cachectic  or  otherwise.  Only  by  a  close  and  exhaustive  scru- 
tiny, and  a  careful  weighing  of  each  particular  symptom,  is  it 
possible  to  meet  the  indications  and  requirements  of  the  par- 
ticular case  in  hand.  Sometimes  so  trifling  a  symptom  as  the 
time  of  aggravation,  whether  morning,  noon  or  night,  furnishes 
the  key  to  the  whole  case.  More  than  once,  when  three  or 
four  different  remedies  seemed  to  be  equally  called  for,  the 
choice  has  been  made  by  the  help  of  so  trifling  a  differential 
point  as  vomiting  without  thirst.     (Antimon.  crud.) 

In  Simple  Diarrhea  the  remedies  most  generally  called 
for  are  as  follows : 

Antimonium  Crud. — Stool  watery,  often  profuse,  alternat- 
ing with  constipation  ;  tongue  coated  white  ;  no  thirst ;  worse 
at  night  and  early  in  the  morning;  cutting  pains  before  stool; 
prolapsus  ani ;  child  cannot  bear  to  be  touched  or  looked  at. 
Violent  vomiting  excited  by  taking  food  or  drink. 

Belladonna. — Stools  thin  with  green  mucus,  bloody  mucus, 
granular,  yellow,  slimy  mucus ;  watery ;  worse  in  the  after- 
noon and  after  sleeping;  colic;  tenesmus  after  stool ;  head  hot ; 
easily  startled ;  rolling  head  from  side  to  side ;  delirium  during 
sleep  or  just  after  stupor  ;  lethargy  with  flushed  face  ;  children 
cry  much  and  are  very  cross ;  tongue  dry  and  red  at  the  tip ; 
sleeps  with  mouth  open  ;  constant  chewing ;  aversion  to  food  ; 
partial  or  general  spasms,  with  unconsciousness ;  involuntary 
urination ;  abdomen  distended  and  tender ;  dry  heat ;  quick, 


INFLAMMATORY  DIARRHEA.  l^l 

hard,  small  pulse  ;  sleepiness  with  restlessness.  Characteristics : 
drowsiness,  with  startings,  dry  heat,  and  frequent  drinking. 

Bryonia. — Stools  brown,  thin,  fecal,  undigested,  frequent, 
involuntary  during  sleep,  smelling  like  rotten  cheese  ;  worse  in 
the  morning  in  hot  weather  ;  often  suppression  of  exanthemata ; 
nausea  after  sitting  up  ;  worse  from  motion  ;  desire  to  get  out 
of  bed ;  desire  for  things  which  are  refused  when  offered. 

Chamomilla. — Stools  green  mucus  ;  mixed  green  and  white 
mucus,  like  chopped  spinach  ;  slimy  mucus;  scalding,  frequent, 
smelling  like  rotten  eggs  ;  worse  during  dentition ;  diarrhea  fol- 
lowing a  cold  ;  colic  during  stool ;  peevishness — children  cry 
much  and  can  only  be  pacified  by  being  carried  about ;  tongue 
and  mouth  dry  ;  moaning  in  sleep.  Best  given  in  recent  attacks  ; 
benefit  of  short  duration, 

Colocynthis.  —  Stools  saffron  yellow ;  frothy,  liquid ;  first 
watery  and  mucus,  then  bilious  and  lastly  bloody,  thin,  greenish, 
slimy  and  watery  ;  worse  after  eating  and  during  dentition ; 
cutting  colic ;  great  urging ;  tongue  coated  white  or  yellow ; 
much  thirst ;  nausea  lasting  until  falling  asleep  and  returning 
after  waking  ;  severe  colicky  pains  are  characteristic. 

Croton  Tig. — Stools  yellow,  watery,  which  come  out  like  a 
shot ;  worse  after  drinking  and  while  nursing  ;  constant  urging 
to  stool ;  dry  parched  lips  ;  excessive  nausea.  The  three  highly 
characteristic  symptoms  of  croton  tig.  are  the  yellow,  watery 
stools,  sudden  expulsion,  and  aggravation  from  eating  and 
drinking. 

Nux  Vomica. — Stools  thin,  brownish  mucus ;  thin,  bloody 
mucus  ;  frequent,  small ;  after  drastic  medicines  or  prolonged 
drugging;  violent  tenesmus;  tongue  coated  thick;  pale,  earthy 
color  of  face ;  gums  swollen,  bleeding ;  bad  smell  from  the 
mouth  ;  thirst;  loss  of  appetite;  frequent  but  ineffectual  efforts 
to  urinate  ;  debility ;  jaundice  ;  much  gas  in  stomach  and  bowels. 

PodopJiyllin.  —  Stools  watery,  greenish  watery  ;  jelly-like 
mucus,  chalk-Hke,  fecal ;  profuse,  frequent,  gushing,  painless  ; 
very  offensive,  like  carrion  ;  worse  in  the  morning  and  at  night, 
worse  after  eating  or  drinking  ;  prolapsus  ani ;  rolling  of  the 
head  during  dentition ;  bad  breath  ;  tongue  dry  and  coated 
yellowish  or  white ;  gagging  or  empty  retching  ;  sallowness  of 
skin  ;  jaundice  characteristics.  The  stools  are  profuse  and  gush- 
ing, each  seeming  to  drain  the  patient  dry.  There  may  be  also 
violent  cramps  ;  changeable  stools  with  meal-like  sediment. 

Sulphur. —  Stools  watery,  frothy,  fetid,  slimy,  excoriating, 
involuntary ;  worse  in  early  morning,  after  taking  milk,  after 
suppressed  eruptions,  during  dentition  ;  open  fontanels  ;  sleep- 
ing with  eyes  half  open ;  wakefulness.  The  early  morning 
exacerbation  is  very  characteristic. 


192  THE  DISEASES  OF  CHILDREN. 

EnterO-COLITIS — Aconite. — Stools  watery,  bloody,  slimy 
mucus,  small,  frequent ;  tenesmus ;  restlessness  ;  won't  be 
covered  up ;  lips  dry  and  parched ;  unquenchable  thirst ; 
nausea,  vomiting;  violent  pains  in  abdomen;  full,  hard,  very 
quick  pulse ;  dry,  hot  skin.  Only  useful  in  beginning  of  acute 
cases. 

Arsenicum.  —  Stools  thick,  dark-green  mucus,  frequent, 
scanty,  corrosive,  offensive,  worse  at  night  and  after  eating  or 
drinking  ;  worse  after  midnight ;  great  restlessness,  constantly 
changing  place ;  violent,  unappeasable  thirst ;  vomiting  after 
eating  or  drinking;  dry  heat ;  great  prostration  ;  rapid  exhaus- 
tion ;  emaciation ;  very  rapid  and  weak  pulse ;  diarrhea  generally 
painless.  The  two  characteristics  of  ars.  are  thirst  and  rest- 
lessness. 

Ipecac. — Stools  green  mucus,  grass-green,  bloody,  fermented  ; 
worse  at  night  and  during  dentition ;  face  pale ;  no  thirst  ; 
great  nausea  ;  flatulent  colic  ;  spasms ;  sleeps  with  eyes  half 
open.  Continuous  nausea  is  the  most  characteristic  symptom 
of  ipecac. 

Iris.  Vers. — Stools  watery,  greenish,  undigested  ;  tenesmus ; 
vomiting  of  ingesta  and  of  bile  ;  vomiting  of  sour  fluid  ;  vomit- 
ing of  sour-smelling  milk  in  children. 

Merc.  Sol.  or  Vivus. — Stools  green  mucus,  bloody  mucus, 
green,  slimy,  bloody,  frequent  scanty,  corrosive  ;  worse  at  night 
and  in  very  hot  weather ;  violent  and  frequent  urging  before 
stool ;  nausea  ;  chilliness ;  pinching  and  cutting  colic  ;  open 
fontanels  ;  large  head  ;  gums  swollen  and  bleed  easily  ;  tongue 
swollen,  soft  and  flabby  ;  impressions  of  teeth  on  tongue  ;  tongue 
coated  white  or  yellowish  ;  increase  of  saliva  or  intense  ptyal- 
ism  ;  violent  thirst ;  frequent  desire  to  urinate  ;  restless  sleep  ; 
sour-smelling  perspiration ;  jaundice.     All  symptoms  intense. 

Pulsatilla. — Stools  greenish,  bilious,  watery,  offensive,  cor- 
rosive, involuntary  ;  worse  at  night ;  after  measles  ;  after  cold 
drinks ;  rumbling  in  bowels  before  stool ;  bad  smell  from 
mouth  ;  saliva  increased ;  flatulent  colic ;  aversion  to  fat,  to 
meat,  to  bread,  to  milk. 

Rheum. — Stools  mucus  and  fecal,  sour-smelling,  fetid  ;  worse 
after  eating;  worse  during  dentition;  before  stool,  colic  and 
urging  ;  restless  ;  demanding  things  with  vehemence  and  crying; 
desire  for  various  kinds  of  food  which  become  repugnant  as 
soon  as  tasted ;  restless  sleep  with  tossing  about,  crying  out, 
and  twitching  of  muscles  of  the  face  and  hands  (bell.);  sour 
smell  of  the  whole  body.  This  last  symptom  is  very  charac- 
teristic. 

Rhus  Tox. — Stools  watery,  thin  red  mucus,  thin  yellow 
mucus,  bloody ;  involuntary — especially  at  night  while  sleep- 


CHOLERA  INFANTUM.  198 

ing  ;  fetid,  frothy,  painless  and  odorless ;  relieved  by  bending 
double  and  when  lying  on  the  abdomen  ;  better  from  warmth  and 
from  continued  motion  ;  cutting  colic  ;  urging  ;  nausea  ;  restless- 
ness ;  pale,  sunken  face  with  blue  rings  around  the  eyes  ;  tongue 
dry,  red  or  brown  and  cracked ;  increase  of  saliva ;  loss  of  appe- 
tite ;  much  thirst,  which  is  worse  at  night ;  thirst  for  cold 
drinks,  especially  for  milk,  which  is  taken  greedily;  trouble- 
some dreams  of  vivid  character — of  hard  work  and  difficulty. 
This  craving  for  cold  drinks  and  the  laborious  dreams  are  very 
characteristic. 

Cholera  Infantum. — Cholera  infantum  or  cholerine  is  the 
most  serious,  although  by  no  means  the  most  common,  of  the 
diarrheal  diseases  of  early  life.  Like  entero-colitis,  it  is  essen- 
tially a  disease  of  the  city,  and  is  found  in  the  alleys  rather 
than  on  the  avenues.  It  is  most  prevalent  during  the  "  heated 
term,"  although  I  have  seen  two  fatal  cases  in  this  city,  as  early 
as  April.  Its  onset  is  sometimes  sudden  and  without  premon- 
itory symptoms.  This,  however,  is  the  exception.  More 
often  there  is  a  preceding  diarrhea  lasting  from  a  few  days  to  a 
week  or  more.  This  prodromal  diarrhea  is  usually  of  mild 
type  and  attracts  but  little  attention.  The  disease  itself  is 
encountered  most  frequently  in  infants  under  eighteen  months 
of  age,  and  the  majority  of  cases  are  under  a  year  old. 

Symptoms. — The  development  of  choleraic  symptoms  is  sud- 
den and  frequently  of  such  severity  that  the  case  terminates 
fatally  in  a  few  hours.  The  two  essential  features  of  the  disease 
are  vomiting  and  purging,  and  either  of  these  symptoms  may 
precede  the  other  or  both  may  appear  simultaneously.  The 
vomiting  is  persistent  and  incessant.  The  vomited  matter  con- 
sists at  first  of  whatever  food  has  been  recently  taken  and,  after 
this  has  been  ejected,  of  serum,  mucus  and  bile.  The  thirst  is 
unappeasable,  and  yet  whatever  is  taken  into  the  stomach, 
whether  food  or  drink,  is  instantly  thrown  up  again.  At  the 
very  commencement  of  the  disease  the  temperature  rises,  and  in 
fatal  cases  may  speedily  reach  as  high  as  105°  Fahr.  or  even 
higher.  In  milder  and  hopeful  cases,  the  thermometer  does  not 
register  above  102°  or  103°  Fahr.  when  taken  per  rectum.  In 
fatal  attacks,  the  temperature  has  been  known  to  rise  just  before 
death  as  high  as  108°.  Either  of  the  temperatures  mentioned 
may  be  present  while  the  surface  of  the  body  feels  cool  to  the 
touch,  with  a  clammy  skin  and  cold  extremities.  The  stools 
are  frequent,  large  and  watery.  At  first  the  discharges  contain 
traces  of  fecal  matters  and  mucus,  especially  if  the  attack  has 
been  preceded  bygastro-intestinal  irritation,  but  quickly  changes 
to  the  appearance  of  dirty  water.  Still  later  the  passages  lose 
D.  C— 13 


194  THE  DISEASES  OF  CHILDREN. 

all  color  and  become  altogether  serous  in  character.  They  are 
frequently  so  thin  and  copious  as  to  soak  through  the  napkin 
and  saturate  the  bed. 

As  they  lose  color  they  gain  proportionately  in  odor,  the 
smell  being  in  some  cases  overpowering.  Occasionally,  how- 
ever, cases  are  met  with  in  which  the  stools  are  odorless.  In 
some  attacks  as  many  as  twelve  or  fifteen  stools  may  occur  in 
half  a  day.  With  this  copious  loss  of  fluids  there  is  correspond- 
ing loss  of  weight  and  strength.  There  is  no  other  disease  of 
childhood  in  which  this  feature  is  so  marked.  Baginsky  records 
a  case  in  which  the  loss  of  weight  was  three  pounds  in  two 
days.     From  the  beginning  the  general  prostration  is  great. 

The  fontanels  are  depressed ;  the  face  becomes  pale  and 
pinched,  and  the  eyes  are  sunken  in  their  sockets.  There  is  at 
first  great  restlessness,  with  cries  and  moans,  and  the  features 
express  the  greatest  anxiety.  As  the  disease  progresses,  this 
condition  gives  way  to  one  of  apathy  or  stupor.  The  pulse  is 
always  accelerated  and  may  beat  as  fast  as  150  or  200  in  the 
minute.  The  respirations  are  somewhat  quickened  from  exhaus- 
tion, but  are  otherwise  normal.  The  urine  is  scant  on  account 
of  the  great  loss  of  fluids  through  the  bowels.  Notwithstand- 
ing the  severity  of  other  symptoms,  the  infant  does  not  seem 
to  experience  any  abdominal  pain  or  tenderness.  In  fatal  cases, 
the  vomiting — and  sometimes  the  diarrhea  also — ceases  for 
some  time  before  death,  which  is  foreshadowed  by  the  absent 
pulse,  the  hyperpyrexia,  the  cold  and  clammy  skin  ;  by  stupor, 
coma  and  convulsions.  In  contradistinction  with  such  cases  as 
these,  some  infants  pass  into  a  state  of  collapse,  which  is  indi- 
cated, by  sub-normal  temperature,  pinched  features  and  cold 
breath.  When  these  symptoms  are  present,  death  is  not  far 
away. 

The  duration  of  cholera  infantum  depends  largely  upon  the 
severity  of  the  attack.  In  some  cases  death  takes  place  in  a  few 
hours.  In  others,  which  terminate  fatally,  life  is  prolonged  for 
several  days.  In  cases  which  recover,  the  severe  symptoms 
which  we  have  just  described  rarely  last  for  more  than  a  day, 
before  signs  of  improvement  are  visible.  The  cessation  of  vom- 
iting is  generally  the  first  of  these  hopeful  signs,  after  which  the 
stools  become  less  frequent  and  contain  more  solid  matter.  The 
color  of  the  discharges  becomes  more  normal.  The  tempera- 
ture falls  and  the  child  becomes  less  nervous.  Restful  sleep  is 
a  symptom  of  the  most  favorable  character.  The  diarrhea  now 
partakes  more  of  a  catarrhal  character,  and  this  may  continue 
for  a  week  or  more.  Relapses  are  not  uncommon,  and  even 
after  all  signs  of  improvement  have  continued  for  several  days, 
the  choleraic  discharges  return  with  generally  fatal  results.     In 


CHOLERA  INFANTUM.  195 

other  cases  a  diarrhea,  precisely  like  that  of  severe  entero-colitis, 
supervenes.  The  serous  discharges  cease  and  are  replaced  by 
those  of  a  brown,  gray  or  greenish  color,  containing  mucus  and 
undigested  food,  and  are  more  or  less  offensive.  There  is  a 
return  of  appetite  and  a  more  restful  condition.  Some  fever 
continues  and  there  is  a  persistent  though  less  rapid  loss  of 
flesh.  These  symptoms,  with  exacerbations  and  remissions, 
may  continue  for  an  indefinite  time  before  convalescence  is 
firmly  established. 

Diagnosis. — There  is  usually  no  difficulty  in  diagnosticating 
this  disease.  The  frequent  and  profuse  discharges,  which  rap- 
idly lose  all  color  as  well  as  consistence  ;  the  incessant  vomiting 
and  inordinate  thirst ;  the  rapid  emaciation,  which  in  well- 
marked  cases  seems  to  progress  visibly  under  your  very  eye  ; 
the  pallid  and  anxious  countenance;  the  extreme  nervousness; 
the  rapid  rise  in  temperature — these  are  symptoms  which 
attend  no  other  disease  and  stamp  its  character  as  plainly  and 
as  clearly  as  symptoms  can.  True  Asiatic  cholera  is  the  only 
affection  with  which  it  is  possible  to  confound  it,  and  when 
this  is  prevalent,  the  differential  diagnosis  is  difficult,  if  not 
impossible. 

Prognosis. — Age,  season  of  year,  previous  physical  condition, 
environment,  all  tend  to  modify  the  prognosis  in  cholera  infan- 
tum. The  younger  the  infant,  the  more  rapid  is  the  exhaus- 
tion, and  the  less  is  the  vital  resistance  to  the  shock  of  the  dis- 
ease ;  the  more  humid  and  hot  the  atmosphere,  the  less  help 
can  we  expect  from  the  eliminating  function  of  the  skin.  The 
violence  exhibited  by  the  early  symptoms,  is  generally  contin- 
ued throughout  the  attack,  and  when  this  is  extreme,  the 
strongest  constitution  is  frequently  unable  to  withstand  it. 
There  are  cases  that  are  fatal  from  the  beginning,  and  no  treat- 
ment, however  skillful  or  prompt,  is  of  any  avail.  This  fact 
should  not  discourage  the  physician  from  employing  all  of  his 
resources,  and  from  hoping  for  good  results,  even  under  the 
most  adverse  circumstances.  The  symptoms  that  are  espe- 
cially perilous  are  uncontrollable  vomiting ;  a  body  temperature 
exceeding  io6°  or  107°  Fahr.,  or  a  sub-normal  temperature  of 
sudden  development ;  profound  nervous  depression,  as  indicated 
by  stupor  or  coma.  Favorable  symptoms  are  a  falling  temper- 
ature, if  it  has  been  previously  abnormally  high ;  or  a  rising 
one,  if  it  has  been  sub-normal ;  quiet  sleep,  if  accompanied  by 
an  improvement  in  the  pulse  and  cutaneous  circulation  is  of 
the  best  augury.  While  the  symptoms  may  be  such  as  to 
necessitate  a  guarded  prognosis  in  a  given  case,  there  are  no 
cases  so  grave  that  the  physician  may  not  console  himself  and 
the  friends  with  that  maxim  which  should  never  be  forgotten 


196  THE  DISEASES  OF  CHILDREN. 

or  ignored,  in  treating  the  affections  of  infants  and  children, 
"While  there  is  life,  there  is  hope." 

Treatment. — There  are  two  requisites  in  the  successful  treat- 
ment of  cases  of  cholera  infantum,  which  must  ever  be  borne 
in  mind,  viz.,  warmth  and  stimulation.  The  first  can  be  secured 
by  the  use  of  hot-water  bags  or  bottles,  distributed  about  the 
patient,  in  addition  to  swathing  the  body  in  hot  flannels.  The 
second  necessity  of  the  case  can  be  best  accomplished  by 
hot-water  enemata.  For  this  purpose  the  water  used  should  be 
small  in  quantity  and  as  hot  as  can  well  be  borne.  In  case  the 
stomach  is  more  intolerant  than  the  rectum,  the  latter  may  be 
used  for  purposes  of  medication,  the  indicated  remedy  being 
added  to  each  enema.  In  the  early  stage  of  the  disease  the 
tongue  is  usually  moist,  and  medicine  may  be  given  on  the 
tongue  dry,  with  less  danger  of  exciting  vomiting  than  when 
given  in  liquid  form  and  swallowed.  To  allay  the  burning 
thirst,  a  piece  of  ice,  wrapped  in  a  piece  of  linen,  may  be  given 
the  child  to  suck.  Water  should  be  given  very  sparingly,  if  at 
all.  Champagne  is  sometimes  retained  and  may  be  useful,  but 
better  still  is  a  little  hot  water  with  a  few  drops  of  brandy  or 
whisky  added.  Koumiss  given  cold,  is  generally  taken  with 
avidity  on  account  of  the  thirst.  Raw-meat  juice  is  especially 
valuable  by  reason  of  the  concentrated  character  of  its  nutritive 
qualities. 

As  soon  as  convalescence  is  established,  its  progress  may  be 
hastened  by  daily  inunctions  of  oil.  For  this  purpose,  plain 
olive  oil  may  be  used,  or,  if  preferred,  cod-liver  oil.  My  friend, 
Dr.  N.  F.  Cooke,  now  deceased,  used  to  advocate  the  use  of  a 
hot  bath  of  chicken-broth,  followed  by  an  inunction  of  the  skin 
with  cocoa  butter,  scented  with  a  little  almond  oil.  Some  of 
the  leading  druggists  here  in  the  city  keep  this  prepared  and 
dispense  it  under  the  name  "  Unguentum  Graecorum."  Cam- 
phor stupes  applied  over  the  abdomen  are  recommended  by 
some  as  being  both  stimulant  and  soothing  in  their  effect. 

During  convalescence,  hygienic  treatment  is  of  the  utmost 
value.  A  change  of  air,  either  to  the  seashore  or  the  moun- 
tains, will  prove  most  advantageous.  A  short  trip  into  the 
country  will  be  beneficial ;  but  a  journey  by  boat,  even  on 
fresh  water,  where  the  air  is  cool  and  invigorating,  is  still 
more  so. 

Medicinal  Treatment. — The  first  remedy  to  be  thought  of  in 
these  cases  is : 

Veratrum  Alb. — It  is  indicated  by  the  profuse  and  watery 
stools  ;  the  incessant  vomiting  ;  the  cold  and  clammy  condition 
of  the  skin  ;  by  the  sudden  onset  of  the  attack ;  by  the  great 
thirst  which  only  provokes  further  emesis,  and  by  the  great 


DTSENTERr.  197 

prostration  which  threatens  collapse.  The  tongue  is  cold,  the 
pulse  almost  imperceptible  and  the  countenance  hippocratic. 

Arsenicum. — Stools  green,  watery,  offensive  ;  vomiting  imme- 
diately after  anything  is  swallowed  ;  great  thirst,  but  no  satis- 
faction  from  drinking ;  great  restlessness  and  irritability ;  cold 
extremities ;  distended  and  tympanitic  abdomen,  or  abdomen 
retracted  and  wrinkled. 

Cuprum. — Stools  green  and  painful;  retching;  violent  but 
ineffectual  efforts  to  vomit.  Especially  indicated  where  there 
is  a  tendency  to  convulsions  from  the  beginning ;  hydrocepha- 
loid  condition ;  stools  frequent,  but  not  very  copious ;  eyes 
deeply  sunken  with  blue  rings  around  them ;  violent  colic  and 
cramps  ;  cramps  in  the  legs  and  feet ;  general  convulsions,  with 
continued  vomiting  and  violent  colic. 

Camphor. — Great  prostration  with  little  or  no  vomiting  and 
purging ;  coldness  with  threatened  collapse ;  attack  very  sud- 
den ;  face  pale,  livid,  purple ;  upper  lip  drawn  up  exposing  the 
teeth  ;  foam  at  the  mouth  ;  eyes  sunken  and  fixed  ;  cold  sweat 
on  the  face ;  great  sinking  and  collapse,  sometimes  without 
stool. 

Ipecac. — Nausea  and  vomiting  predominate  ;  stools  green  as 
grass,  or  fermented  like  yeast ;  face  pale  and  sunken  ;  flatulent 
colic  ;  sleeps  with  eyes  half  open. 

Argentum  Nitrate. — Stools  green  mucus,  frequent  and  fetid  ; 
painless,  accompanied  with  much  noisy  flatus  ;  burning  in  stom- 
ach ;  child  cries  for  sugar  and  will  take  nothing  else ;  nausea, 
with  loud  eructations ;  chilliness.  The  principal  characteristic 
of  this  remedy  is,  that  it  occurs  in  children  inordinately  fond 
of  sugar  and  sweet  things,  and  who  clamor  for  them  even  when 
sick. 

See  also  podophyllin,  ferrum  phos.,  kreasote,  phosphorus, 
tartar  emetic,  ethusa,  secale  corn,  and  phosphoric  acid. 

DYSENTERY. 

This  disease,  which  is  often  referred  to  as  "  bloody  flux," 
is  so  much  more  common  to  adults  than  to  children  that  it 
scarcely  deserves  a  place  in  a  work  like  this.  A  few  words, 
however,  on  the  subject  may  not  be  out  of  place,  since  the 
disease,  while  rare,  is  occasionally  met  with  in  infancy  and 
childhood.  When  it  does  thus  occur,  it  is  almost  always 
in  combination  with  one  or  the  other  affections  already  de- 
scribed. In  very  rare  cases,  however,  it  may  occur  idiopath- 
ically,  and  when  it  does  so  it  has  all  the  symptoms  and  charac- 
teristics which  appertain  to  it  in  the  adult. 

It  affects  principally  the  rectum  and  lower  portion  of  the 


198  THE  DISEASES  OF  CHILDREN. 

colon,  the  mucous  membrane  of  which  becoming  inflamed  or 
ulcerated,  gives  rise  to  pain,  tenesmus  and  passages  of  a  muco- 
purulent character.  It  is  an  acute  febrile  disease,  usually  of 
short  duration,  and  is  sometimes  met  with  as  an  epidemic 
extending  over  large  districts.  In  some  portions  of  the  country- 
it  is  said  to  be  endemic.  It  is  more  often  sporadic,  and  may 
follow  measles  as  a  sequela.  According  to  Condie,  a  few  days 
of  cool,  rainy  weather  occurring  in  the  summer,  will  often 
cause  the  prevailing  bowel  complaints  of  children  to  assume  a 
dysenteric  character.  It  is  extremely  rare  in  early  infancy  and 
never  occurs  in  children  at  the  breast.  The  onset  is  sometimes 
abrupt  and  sometimes  gradual.  In  the  former  case  the  temper- 
ature may  quickly  rise  to  104°  or  105°  Fahr.,  while  in  the  latter 
there  may  be  no  elevation  of  temperature  whatever.  There 
may  be  severe  nervous  disturbance  with  delirium,  but  no  vom- 
iting, as  a  rule.  The  discharges  consist  of  almost  pure  mucus 
or  mucus  streaked  with  blood,  and  sometimes  of  pure  blood. 
There  is  considerable  tenesmus,  which  is  accompanied  with 
griping  pain.  The  stools  are  small  and  frequent,  sometimes  as 
often  as  every  half-hour.  When  this  is  the  case,  the  loss  of 
body  weight  and  prostration  are  rapid  and  sometimes  extreme. 
Prolapsus  ani,  as  a  result  from  straining,  is  not  uncommon. 
The  disease  in  sub-acute  cases  is  very  apt  to  assume  after  a  time 
the  symptoms  of  an  ordinary  entero-colitis  and  run  a  slow  and 
indefinite  course,  attended  by  frequent  relapses  and  an  uncer- 
tain outcome. 

Symptoms. — These  are  sometimes  so  similar  to  those  already 
described  under  the  head  of  entero-colitis  that  there  is  difficulty 
in  some  cases  of  making  a  satisfactory  differential  diagnosis. 
Ordinarily,  however,  the  affection  is  readily  recognized.  The 
absence  of  vomiting  is  marked.  There  is  more  pain,  and  the 
pain  is  accompanied  with  uncontrollable  tenesmus.  The  dis- 
charges, after  the  first  one  or  two,  cease  to  be  fecal  and  are 
mucus  or  consist  of  blood  and  mucus.  The  fever  is  less  high 
and  there  is  but  little  thirst. 

The  prognosis  is  usually  good,  except  in  cases  of  broken 
health  from  other  causes,  and  where  the  disease  sets  in  with 
exceptional  violence. 

Treatment. — But  little  need  be  said  regarding  treatment  in 
addition  to  that  given  to  other  forms  of  bowel  trouble.  The 
same  hygienic  and  auxiliary  measures  already  advocated 
are  equally  admissible  here.  The  remedies  whose  charac- 
teristics have  already  been  given  may  also  be  consulted. 
The  two  following  remedies,  however,  have  a  special  applica- 
tion to  dysentery,  and  when  indicated  will  be  found  of  great 
value. 


D  rSEN  TER  r.  199 

Mercurius  Cor. — Stools  consist  almost  wholly  of  blood  ;  urine 
hot,  scalding,  bloody,  scanty  or  suppressed ;  much  vesical 
tenesmus. 

RJius  Tox. — The  stools  are  mucus  rather  than  bloody,  and 
often  assume  an  appearance  like  the  scrapings  of  raw  beef ; 
involuntary  stools;  pains  in  abdomen  and  limbs  are  worse 
when  patient  is  quiet  and  better  from  moving  about ;  worse  at 
night  and  particularly  after  midnight. 


CHAPTER  V. 

CONSTIPATION. 

Definition. — The  terms  diarrhea  and  constipation  are  only 
used  relatively  by  intelligent  people.  During  infancy  and 
childhood,  the  number  of  daily  evacuations  from  the  bowels 
differs  with  different  children  and  varies  considerably  in  the 
same  child.  This  difference  may  be  quite  marked  without 
being  in  any  sense  pathological ;  but  when  there  is  an  interval 
of  twenty-four  hours  between  evacuations  in  an  infant  under 
three  months  of  age,  or  a  much  longer  interval  than  this  in 
older  children,  a  constipated  condition  may  be  said  to  exist. 
In  early  life  the  digestive  function  is  much  more  active  than  at 
a  later  period,  and  the  digestive  process  is  not  complete  until 
the  egesta  are  duly  and  naturally  expelled.  The  alimentary 
canal  is  the  great  sewer  of  the  body,  and  upon  its  permeability 
and  normal  activity  depend  the  health  of  the  entire  organism. 
A  mechanical  closure  of  the  bowel,  whether  congenital  or 
acquired,  is  always  inimical  to  life.  With  cases  of  imperfect 
bowel  or  mechanical  obstruction  of  accidental  cause,  we  have 
nothing  to  do,  since  they  are  treated  of -in  works  on  surgery. 
It  is  with  cases  of  functional  deficiency  or  inefficiency,  by 
reason  of  which  the  bowels  fail  to  act  with  normal  and  neces- 
sary frequency,  that  we  have  here  to  deal. 

Frequency. — The  fact  that  diarrhea  is  so  very  common  in 
early  life  would  lead  one  naturally  to  infer  that  constipation — 
its  opposite — would  be  equally  common.  But  such  is  by  no 
means  the  case.  In  our  own  experience,  it  is  very  uncommon 
indeed,  and  when  it  does  occur,  it  is  so  obviously  due  to  errors 
in  diet,  that  all  the  treatment  that  is  usually  necessary  is  to 
change  the  diet,  to  effect  a  cure.  Our  own  experience,  how- 
ever, is  evidently  exceptional,  for  nearly  all  writers  on  Pedol- 
ogy assert  that  constipation  is  very  frecfuent  among  children. 
The  physiological  action  of  the  colon — which  is  the  portion  of 
the  bowel  chiefly  involved  in  constipation — requires  a  certain 
amount  of  stimulus  which  comes  from  fecal  accumulation. 
This  fecal  accumulation  is  partly  the  refuse  products  of  diges- 
tion, and  partly  the  effete  matters  which  come  from  incessant 
tissue  waste.  Constipation  results  when  the  peristaltic  action 
(200) 


C  ONS  TIP  A  TION.  201 

of  the  bowel  fails  to  carry  along  these  matters  to  their  natural 
outlet.  Such  a  condition  may  be  due  to  atony  of  the  bowel, 
which  follows  over-stimulation  from  too  coarse  food  or  the  use 
of  purgative  medicines.  The  first  effect  of  such  food  or  medi- 
cine is  to  produce  what  might  be  styled  a  traumatic  diarrhea, 
and  the  reactive  or  secondary  effect  is  constipation.  It  ought 
not  to  be  necessary  to  say — certainly  not  to  students  and  practi- 
tioners of  homeopathy — that  purgatives  and  laxatives  should 
never  be  given  to  children  to  relieve  functional  disturbance  of 
the  bowels.  The  most  obstinate  cases  of  constipation  that 
come  under  the  physician's  care  are  of  this  kind.  Castor  oil, 
castoria,  calomel,  rhubarb,  and  all  that  class  of  remedies  for 
constipation  should  be  relegated  to  the  past.  They  are  worse 
than  useless,  for  the  more  they  are  taken,  the  more  will  they 
be  needed.  Even  old-school  authorities  have  learned  better 
than  to  advocate  them.  When  a  condition  of  atony  exists, 
such  as  is  here  indicated,  no  matter  how  it  has  been  produced, 
more  or  less  impaction  of  the  colon  is  the  result,  and  the  stools 
when  ultimately  voided  are  dry,  hard  and  painful. 

One  of  the  chief  causes  of  constipation  in  infancy  is  the  lack 
of  sufificient  fluid  in  the  system.  The  food  is  given  too  thick 
or  too  little  drink  is  given  in  addition  to  the  food.  Infants 
often  cry  from  thirst  when  their  desire  is  mistaken  for  hunger. 
When  too  young  to  talk  or  express  their  wants,  drink  should 
be  offered  to  them  several  times  daily.  It  will  often  be  found 
more  acceptable  than  food.  Another  of  the  causes  of  consti- 
pation in  infancy  is  deficient  intestinal  secretion,  due  to  gland- 
ular inactivity  or  to  some  fault  of  the  mucous  membrane  itself. 
In  either  case  the  result  is  the  same.  Deficiency  of  bile  causes 
fermentation  and  fills  the  bowels  with  gas,  which  in  time  causes 
a  quasi  paralytic  condition  of  the  bowels  from  distension.  All 
quieting  medicines,  such  as  soothing  syrups,  cordials,  etc.,  con- 
tain some  form  of  opium,  which  is  always  constipating  and 
should  never  be  used  in  the  nursery,  if  for  no  other  reason  than 
this.  Certain  diseases  of  the  nervous  system  are  well  known  to 
be  attended  by  constipation  as  one  of  their  prominent  symp- 
toms. Thus  meningitis,  myelitis  and  hydrocephalus  are  diag- 
nosticated. "  The  bowels  are  sluggish  in  all  diseases  of  the 
cerebro-spinal  system,  due  in  part  to  the  interruptions  in  the 
motor  nerve-currents,  or  to  a  state  of  tonic  contraction  in  the 
abdominal  and  intestinal  structures."  In  all  cases  where  no 
movement  of  the  bowels  occurs  soon  after  birth — say  within 
twenty-four  or  thirty-six  hours — the  anus  should  be  inspected 
to  ascertain  if  it  be  pervious  or  not. 

In  nurslings,  after  excluding  congenital  defects,  we  should 
look  to  the  mother  for  the  cause  of  constipation.     If  she  is  of 


202  THE  DISEASES  OF  CHILDREN. 

constipated  habit,  that  should  be  corrected  and  her  diet  be  so 
arranged  as  to  ensure  a  regular  daily  stool. 

Treatment. — Only  in  exceptional  cases  are  medicines  or 
drugs  necessary  to  cure  constipation  in  infancy.  Immediate 
relief  can  nearly  always  be  secured  by  the  use  of  warm-water 
enemata.  These  need  not  be  large  for  young  infants.  Usually 
two  to  four  fluidrachms  are  sufficient.  Their  efficiency  is 
increased  by  the  addition  of  glycerine  in  the  proportion  of  one- 
half  glycerine  to  one-half  water.  Suppositories  of  soap,  gluten, 
or  glycerine  are  also  useful  and  when  judiciously  employed  do 
no  possible  harm.  They  generally  produce  an  immediate  action 
and  should  therefore  be  used  at  the  time  when  the  child  has 
previously  had  its  habitual  stool.  Regularity  in  the  action  of 
the  bowels  is  very  essential.  Many  cases  of  constipation  are 
due  entirely  to  carelessness.  The  bowels  can  be  educated,  with 
a  little  care,  to  act  with  the  regularity  of  clockwork.  As  soon 
as  a  child  is  able  to  walk  alone,  or  even  earlier,  it  should  be 
taught  to  expect  an  evacuation  of  the  bowels  at  a  certain  time 
of  day,  and  when  this  time  comes  it  should  be  placed  on  a  chair 
suitable  for  the  purpose.  Nothing  should  be  allowed  to  inter- 
fere with  this  regularity  of  habit.  Older  children  may  establish 
the  habit,  even  when  the  bowels  are  sluggish  and  irregular,  by 
drinking  a  glass  of  cold  water  a  little  time  before  a  stool  is 
desired. 

Excess  of  water,  /.  e.,  more  than  is  needed  by  the  system  to 
maintain  the  secretions  and  the  due  fluidity  of  the  blood,  when 
taken  into  the  stomach  does  not  enter  the  general  circulation 
or  pass  off  by  the  kidneys,  but  goes  into  the  bowels  to  moisten 
the  excreta  and  facilitate  their  expulsion. 

Massage  of  the  abdomen  is  also  useful  and  may  be  employed 
with  infants  of  any  age.  In  obstinate  cases,  where  such  meas- 
ures as  have  been  suggested  prove  inadequate,  electricity  will 
be  found  helpful.  The  faradic  current  is  the  one  we  have 
mostly  employed. 

The  main  dependence,  however,  in  the  treatment  of  consti- 
pation should  be  on  diet.  This  should  depend  on  the  age 
of  the  child,  but  in  all  cases  should  consist  of  food  of  coarser 
quality  than  required  or  admissible  under  other  circumstances. 
Starchy  foods  should  be  avoided  for  reasons  already  given. 
Concentrated  aliment,  such  as  eggs  and  cheese,  are  very  con- 
stipating in  their  nature.  For  children  over  two  years  of  age, 
oatmeal  with  a  little  molasses  on  it  may  be  given,  and  this 
may  be  changed  to  mush  made  of  entire  wheat  or  unbolted 
flour,  or  corn  meal.  Stewed  fruits  or  baked  apples  are  laxative 
and  may  be  given  to  children  who  are  having  a  mixed  diet. 

For  bottle-fed  infants  there  is  no  food  so  well  adapted  for 


C  OJVS  TIP  A  TI  ON.  203 

regulating  the  bowels  as  Liebig's  dextrinized  food.  This  is  a 
food  prepared,  as  we  have  before  stated,  from  wheat  flour 
mixed  with  malted  barley.  Under  heat,  the  starch  of  these 
cereals  is  transformed  into  glucose,  which  has  decided  laxative 
properties,  especially  when  administered  without  milk.  This 
is  one  of  the  reasons,  and  the  principal  one,  why  we  are  so 
partial  to  Mellin's  food  for  infants.  It  is  prepared  after  the 
Liebig  formula,  and  by  varying  the  proportions  of  milk,  when 
preparing  it  for  a  meal,  it  can  be  made  laxative  or  otherwise  at 
pleasure.  Prepared  with  water  or  cream,  it  can  be  given 
freely  to  a  constipated  infant  with  good  effect ;  but  when  the 
bowels  are  sufficiently  loose,  it  should  be  mixed  with  boiled 
milk  in  due  proportion,  and  with  a  little  experience  and  judg- 
ment the  evacuations  can  be  regulated  to  a  nicety.  A  pure 
milk  diet — that  is,  consisting  of  cow's  milk  exclusively — is 
almost  certain  to  result  in  constipation  sooner  or  later. 

Post-mortem  examinations  of  the  intestines  of  milk-fed 
infants  often  show  the  colon  coated  on  its  inner  surface  almost 
to  occlusion  with  undigested  or  partially  digested  casein,  which 
has  been  accumulating  in  this  locality  for  an  indefinite  period. 
For  this  reason  it  is  well  to  occasionally  give  to  infants  at  the 
breast,  if  constipated,  an  occasional  feeding  of  thin  Mellin's 
food,  which  acts  as  a  diastase  on  the  casein  and  carries  forward 
the  digestive  process,  in  such  cases  as  those  just  mentioned,  to 
perfect  completion. 

It  seems  superfluous,  after  what  has  been  already  said  about 
the  success  of  hygienic  and  prophylactic  treatment  in  consti- 
pation, to  add  anything  in  the  way  of  medication.  But  some- 
times there  are  concomitant  symptoms  that  require  attention, 
and  medicines  may  afford  relief  in  cases  in  which  a  change  of 
diet  may  effect  a  permanent  cure.  The  following  remedies  may 
be  consulted : 

Bryonia. — The  stools  are  very  dry,  as  if  burnt,  and  of  a  dark 
color ;  alternation  of  constipation  with  diarrhea ;  soreness  of 
stomach  and  head ;  dry  lips  and  mouth. 

Graphites. — The  stools  are  of  an  uncommon  size,  very  large, 
and  the  child  has  more  or  less  humid  eruption  over  the  body, 
behind  the  ears,  on  the  face,  or  in  the  groins. 

Nux  Vomica. — This  is  the  chief  remedy  for  constipation,  and 
is  especially  valuable  in  the  gastric  derangement,  which  often- 
times accompanies  it.  In  cases  where  it  is  indicated,  the 
stools  are  large  and  difficult ;  they  are  dry  and  hard,  or  small, 
frequent  and  painful ;  much  colic. 

A  somewhat  empirical  practice,  but  one  indorsed  by  suc- 
cessful experience,  is  to  give  sulphur  at  night  and  nux  vomica 
in  the  morning. 


204  THE  DISEASES  OF  CHILDREN. 

Colic  :  Enteralgia. — By  giving  a  paragraph  to  this  affec- 
tion, it  is  not  intended  to  dignify  it  with  the  title  of  disease,  for 
such  it  is  not.  It  is  never  more  than  a  symptom,  and  yet  the 
pain  which  accompanies  it,  may  be  so  severe  as  to  cause  con- 
vulsions or  even  death.  It  is  very  frequent  during  the  first  few 
months  of  life,  and  may  be  produced  by  causes  so  trifling  that 
their  nature  may  elude  the  closest  investigation. 

Some  children  seem  to  have  been  born  colicky,  for,  do  what 
you  will,  the  paroxysms  recur  again  and  again.  As  a  rule,  how- 
ever, colic  is  a  result  of  indigestion  and  is  a  common  result  of 
constipation.  This  is  not  always  the  case,  for  enteric  colic  may 
be  present  when  the  bowels  are  regular  or  more  frequent  than 
natural.  There  is  a  prevalent  idea  that  certain  articles  of  food 
partaken  of  by  the  mother  tend  to  produce  colic  in  the  nursing 
infant,  and  there  seems  to  be  good  ground  for  this  belief. 
These  foods  are  mainly  acid  fruits  and  certain  vegetables,  well 
known  to  produce  flatulence  when  taken  into  the  average  stom- 
ach. Theoretically,  when  vegetable  acids  are  taken  up  by  the 
blood,  they  are  converted  into  carbonic  acid,  which  speedily 
combines  with  soda  and  potassa  to  form  alkaline  carbonates. 
Physiological  chemistry  teaches  that  this  is  their  ultimate  goal^ 
and  teaches  it  without  qualification  or  reservation. 

In  a  perfectly  healthy  organization,  with  digestion  quite  up 
to  the  physiological  standard,  this  is  doubtless  true,  and  when 
it  is  true,  acids  may  be  eaten  by  a  nursing  woman  without  fear 
of  being  disturbed  by  colic  in  her  nursling,  for  long  before 
these  acids  could  reach  the  milk  glands  their  acidity  would  be 
destroyed. 

But  perfect  digestion  is  not  always  enjoyed  by  the  mother  or 
nurse,  and  the  best  regulated  digestion  will  sometimes  go  wrong, 
in  which  case  the  fruit  acids  may  not  be  entirely  transformed 
into  alkaline  carbonates,  but  reach  the  breasts  in  an  unchanged 
or  partially  changed  form,  and  colic  may  be  the  result. 

Experience  is  the  best  guide,  and  a  nursing  woman  should 
avoid  those  articles  of  diet  that  she  feels  uncertain  about  di- 
gesting easily.  If  any  particular  food  gives  her  infant  colic, 
she  should  thereafter  abstain  from  it,  whether  she  craves  it  or 
not.  There  are  other  articles  in  plenty,  that  she  may  eat  as  a 
substitute,  about  which  there  can  be  no  question. 

When  colic  does  occur  it  is  usually  indicative  of  disordered 
digestion,  for  it  is  rarely  present  when  digestion  and  assimilation 
are  carried  on  properly.  This  is  clearly  demonstrated  by  the 
character  of  the  stools,  which  are  usually,  under  these  circum- 
stances, either  green  and  accompanied  with  mucus  or  filled  with 
small  masses  of  undigested  curd. 

In  older  children,  colic  is  often  caused  by  eating  unripe  or 


COLIC:  ENTERALGIA.  205 

indigestible  fruit,  such  as  green  apples  or  gooseberries,  or  drink- 
ing large  quantities  of  cold  water  when  the  stomach  is  empty, 
or  the  body  overheated.  Worms  in  the  bowels,  or  intestinal 
obstruction  from  any  cause,  are  capable  of  causing  the  disorder. 

The  causes  of  colic  are  so  various,  and  cover  so  wide  a  range  of 
danger — from  a  trifling  and  transient  flatus  to  intussusception — 
that  it  should  never  be  treated  lightly  or  carelessly.  In  most 
cases  the  affection  is  paroxysmal,  easily  palliated,  and  unat- 
tended with  peril.  Its  victims,  although  in  an  agony  of  pain 
while  the  paroxysm  lasts,  grow  and  thrive  as  if  entirely  well. 
In  some  families  with  a  large  number  of  children,  it  is  so  uni- 
form in  the  experience  of  each  child  as  to  seem  like  a  matter  of 
inheritance. 

In  these  cases,  no  changes  in  the  food  supply  seem  to  make 
any  special  difference  in  the  frequency  or  severity  of  the  at- 
tacks, and  the  inevitable  conclusion  is  reached,  that  the  trouble 
is  neurotic,  being  devoid  of  fever,  tenderness  or  other  evidences 
of  inflammation.  It  is  a  mild  neuralgia  of  the  intestinal  tunics 
and  as  such  may  be  periodical  in  its  visitations. 

Infants  who  are  prone  to  have  colic  usually  develop  the  ten- 
dency during  the  first  few  days  or  weeks  of  life,  and  such  cases 
continue  to  suffer  at  intervals  until  the  process  of  teething  is 
well  advanced,  or  until  the  age  of  eight  or  nine  months  is 
reached.  If  the  first  month  of  infantile  life  is  passed  without 
colic,  the  exemption  is  usually  permanent,  except  as  due  to 
dietetic  irregularities  or  excess. 

Symptoms. — Attacks  of  colic  usually  begin  suddenly  and 
may  even  awaken  the  infant  out  of  a  sound  sleep.  The  child 
draws  up  the  legs  and  instinctively  bends  the  body  forward  to 
relax  the  abdominal  muscles.  There  is  violent  alternate  flex- 
ing and  straightening  of  the  lower  extremities,  tossing  and  con- 
tortion of  the  entire  body,  thrusting  the  clenched  fists  into  the 
mouth.  There  is  usually  more  or  less  flatulence,  but  the  suf- 
fering may  be  intense,  without  any  distension  whatever,  and 
even  with  retraction  of  the  umbilicus. 

Sometimes  temporary  relief  is  experienced  by  laying  the 
child  across  the  lap,  producing  steady  pressure  over  the  abdo- 
men ;  while  at  other  times  the  child  seems  to  feel  relief  from 
being  jumped  up  and  down,  which  probably  moves  the  gas 
about  from  place  to  place.  When  the  abdomen  is  distended 
with  flatus,  it  is  not  equally  so ;  it  may  be  conical  along  the 
center,  and  the  small  intestines  be  more  involved  than  the 
colon ;  but  more  often  the  seat  of  disturbance  seems  to  be  in 
the  large  bowel,  and  the  pain  is  in  the  direction  of  the  transverse 
colon.  In  addition  to  the  symptoms  just  enumerated,  the 
child  shrieks  out  with  pain,  the  angles  of  the  mouth  are  drawn 


206  THE  DISEASES  OF  CHILDREN. 

down  and  the  face  is  pitiable  to  see.  Syncope  and  convulsions 
may  happen  in  severe  cases.  The  paroxysms  may  last  from  a 
few  minutes  to  several  hours,  and  may  recur  at  stated  periods 
for  days  together.  The  appetite  is  oftentimes  unimpaired  and 
the  child  takes  food  eagerly  or  even  greedily.  It  also  sleeps 
well  when  not  suffering  from  an  attack. 

Notwithstanding  the  torture  which  the  child  undergoes,  its 
general  health  may  not  suffer  in  the  least.  It  will  grow  strong 
and  fat  without  showing  the  slightest  evidence  of  general  ill- 
health.  The  affection  is  to  be  distinguished  from  peritonitis  and 
from  inflammation  of  the  bowels,  by  the  suddenness  of  the 
attack,  the  violence  of  the  pain,  and  the  freedom  from  suffering 
between  the  paroxysms;  by  the  quietude  of  the  pulse,  the 
absence  of  fever,  and  the  relief  obtained  from  pressure.  Chil- 
dren will  often,  when  pale  with  agony,  throw  themselves  across 
a  chair  to  obtain  the  relief  which  pressure  affords. 

Treatment. — Before  active  measures  are  instituted  for  the 
relief  of  supposed  colic,  it  is  always  well  to  examine  the  infant's 
clothing,  for  many  a  case  of  enteralgia  has  been  promptly  re- 
lieved by  finding  a  pin  that  had  been  piercing  the  infant's 
anatomy.  The  palliative  measures  that  are  mostly  to  be  de- 
pended upon  are  enemas  of  hot  water,  hot  fomentations  applied 
to  the  abdomen,  or  the  hot  bath.  A  drink  of  hot  water  is  also 
very  serviceable.  Gin  and  brandy  are  never  required,  and 
when  given  do  more  harm  than  good.  The  remedies  which  are 
more  commonly  called  for  are  colocynthis,  chamomilla  and  nux 
vomica,  and  their  value  is  in  the  order  named.  In  cases  of 
great  pain,  coupled  with  obstinate  constipation,  plumbum  will 
often  afford  prompt  relief.  Other  remedies  may  be  needed^ 
but  their  selection  will  depend  on  concomitant  symptoms  that 
cannot  here  be  anticipated. 


CHAPTER   VI. 

INTESTINAL    PARASITES. 

Worms. — Twenty-one  different  kinds  of  animal  parasites 
have  been  found  to  inhabit  the  intestinal  canal  of  man.  Many 
of  these,  however,  are  of  microscopical  size  and  produce  symp- 
toms of  such  indefinite  character  that  they  are  scarcely  worthy 
of  notice.  Others,  again,  are  only  found  in  distant  lands  among 
savages  or  semi-civilized  tribes,  and  are  therefore  only  of  interest 
to  the  helminthologist  or  the  collector  of  medical  curios.  Only 
some  seven  varieties  of  intestinal  worms  are  known  to  sustain 
a  causative  relation  to  certain  pathological  states,  which  give 
them  special  interest  to  the  pedologist  or  the  general  practi- 
tioner of  medicine.  These  are  the  ascaris  lumbricoides,  or  round 
worm  ;  the  oxyuris  vermiculosis,  or  thread  worm  ;  the  bothrio- 
cephalus  latus,  and  three  species  of  tenia,  or  tape  worms  ; 
and  the  trichocephalus  dispar,  or  whip  worms.  The  trichina 
spiralis  is  not  included  above  because  it  rarely  molests  children. 

Any  of  these  parasites  may  exist  for  a  time  in  the  alimentary 
canal  without  giving  rise  to  symptoms  which  are  apt  to  attract 
notice.  But  some  of  them — any  of  them,  indeed — may  attain 
such  size  or  multiply  in^such  numbers  as  to  prejudice  health, 
if  not  to  jeopardize  life  itself.  In  a  general  way  it  may  be  said 
that  "  worms "  are  by  no  means  as  common  in  the  human 
cloaca  as  people  commonly  imagine.  In  opposition  to  current 
belief,  they  are  comparatively  rare.  Not  only  is  this  true,  but 
the  human  system  is  wonderfully  tolerant  of  all  forms  of  para- 
sites, and  harbors  them  undoubtedly  in  multitudes  of  cases, 
where  their  presence  is  never  suspected  and  when  no  symptom 
of  their  existence  is  appreciable.  This  fact,  however,  does  not 
prove  the  truth  of  the  position  assumed  by  some  pathologists 
of  the  last  century,  that  "  these  parasites  exert  a  wholesome  ef- 
fect upon  the  economy  and  aid  digestion  by  increasing  the  secre- 
tion of  mucus  and  promoting  the  peristalsis  of  the  intestine."* 

On  the  other  hand,  they  must  be  considered  to  be  the  occa- 
sional cause  of  serious  derangement  and  possibly,  in  very  rare 
instances,  of  death.     A  study  of  the  life  history  of  these  para- 


*  Dr.  C.  W'.  Earl,  in  "  Cyclopedia  of  Diseases  of  Children." 

(207) 


208  THE  DISEASES  OF  CHILDREN. 

sites  is  necessary  in  order  to  know  how  to  treat  them  success- 
fully. 

The  ascaris  lumbricoides,  or  round  worm,  bears  a  striking 
resemblance  to  the  common  earth-worm  of  the  gardens,  except 
being  longer,  whiter  in  color  and  more  tapering  at  the  extrem- 
ities. The  male  is  the  smaller  of  the  two  sexes  and  is  from  four 
to  six  inches  in  length,  while  the  female  is  from  ten  to  twelve 
inches  long.  The  body  is  firm  and  elastic  and  nearly  trans- 
parent. The  head  is  separated  from  the  body  by  a  circular 
depression,  and  has  three  small  elevations,  between  which  lie  the 
teeth.  When  a  female  ascaris  is  subjected  to  slight  pressure,  the 
extended  ovaries  may  be  seen  hanging  from  the  ventral  surface 
like  a  bundle  of  processes.  The  eggs  are  oval  in  form,  about 
3^  of  an  inch  in  length,  and  it  has  been  estimated  that  a  single 
individual  may  contain  as  many  as  sixty-four  millions  of  them. 
These  ova  do  not  contain  a  formed  embryo  at  the  time  of  their 
discharge,  but  are  almost  indestructible  and  may  remain  dor- 
mant for  a  very  long  period.  It  is  supposed  that  in  this  or  in 
the  larval  state  they  are  taken  into  the  stomach  by  means  of 
uncooked  food  or  unfiltered  water.  The  ascaris  lumbri- 
coides infests  children  between  three  and  ten  years  of  age. 
Its  preferred  habitat  is  the  small  intestine,  but  it  is  migra- 
tory in  its  nature  and  is  prone  to  find  its  way  into  the 
large  bowel  and  out  through  the  anus.  It  also  ascends  to  the 
stomach  and  even  into  the  esophagus.  It  may  penetrate  the 
hepatic  and  pancreatic  ducts,  and  in  very  rare  cases,  where  the 
intestines  have  been  perforated  by  ulceration,  these  worms  in 
great  numbers  have  been  found  in  the  cavity  of  the  abdomen. 
They  are  rarely  solitary  like  the  tape  worm,  and  yet,  notwith- 
standing this  great  number  of  ova  developed  by  the  female, 
the  number  of  mature  ascarides  is  seldom  over  four  or  five. 

The  oxyuris  verrniculosis,  or  seat  worm,  commonly  known 
as  the  thread  worm,  or  "  pin  worm,"  is  the  one  most  frequently 
found  in  early  life.  It  varies  in  length  from  one  to  five  lines, 
the  female  being  twice  as  long  as  the  male.  There  is  a  differ- 
ence of  opinion  among  authorities  as  to  what  part  of  the 
colon  is  the  preferred  home  of  this  parasite,  some  holding  that 
it  is  the  cecum,  while  others — and  the  weight  of  evidence  is 
in  their  favor — maintain  that  it  is  the  rectum  and  the  sigmoid 
flexure  of  the  colon.  It  is  whitish  or  semi-transparent  in 
appearance.  The  eggs  are  oval,  and  each  contams  a  formed 
embryo.  They  are  introduced  by  the  mouth  and  hatshed  in 
the  stomach,  from  whence  they  pass  onward  to  their  habitat 
in  the  large  intestine.  They  often  crawl  out  of  the  anus  and 
enter  the  vagina  or  urethra,  or  get  under  the  prepuce.  In 
either  of  the  latter  locations  they  produce  the  most  intolerable 


WORMS.  209 

itching.  They  occur  chiefly  in  young  children,  but  no  age  is 
exempt  from  their  presence.  They  propagate  with  great 
rapidity ;  and  sometimes  exist  in  such  numbers  that  they  line 
the  intestine  like  fur.  When  they  are  so  abundant  as  this, 
they  are  found  above  the  illeo-cecal  valve  as  well  as  below  it, 
and  are  especially  numerous  in  the  appendix  vermiformis. 

The  trichocephalus  dispar,  is  of  but  little  importance  clin- 
ically, since  it  occurs  but  rarely  in  childhood,  and  it  is  not 
known  that  its  presence  produces  any  particular  symptoms 
which  are  recognizable.  It  is  found  more  commonly  in  the 
cecum  and  less  often  in  the  ileum  and  appendix  vermiformis. 
It  is  sometimes  called  the  whip  woiTn  from  its  shape,  the  pos- 
terior or  thick  portion  of  the  female  being  bent  or  curved  like 
the  stock  of  a  hunting  whip,  while  that  of  the  male  is  rolled  in 
the  spiral  form.  They  are  supposed  to  be  introduced  into  the 
system  by  means  of  uncooked  fruit  and  vegetables. 

The  tape  worms  are  by  no  means  as  common  as  those  just 
mentioned,  although  they  are  occasionally  found  in  children  of 
all  ages,  except  nurslings.  There  are  several  varieties  of  tape 
worms,  the  bothricephalus  latus  being  the  largest.  This  worm 
attains  a  length  of  from  fifteen  to  twenty-four  feet,  but  is  rarely 
found  outside  of  Europe,  and  then  it  is  chiefly  met  in  countries 
bordering  on  inland  lakes  and  seas,  where  the  inhabitants  live 
largely  on  fish.  The  two  varieties  most  frequent  in  North  Amer- 
ica and  Europe  are  the  tenia  solium  and  the  tenia  saginata 
or  medio  canellata.  The  latter  is  the  beef  tape  worm  ;  the  former 
is  the  pork  tape  worm.  The  tape  worm  is  an  hermaphrodite, 
each  segment  containing  the  two  sexual  organs.  The  head  or 
scolex  is  small,  being  about  the  size  of  a  pin-head.  The  devel- 
opment of  the  worm  proceeds  from  this  head,  segment  after 
segment  being  produced  by  a  sort  of  budding  process.  These 
segments  are  attached  to  each  other  at  their  extremities,  and  as 
they  become  further  and  further  removed  from  the  head,  they 
become  larger  and  more  matured.  When  they  have  attained  to 
full  maturity,  they  are  detached  and  enter  upon  an  independent 
existence.  Breaking  the  chain  of  segments  does  not  compro- 
mise the  life  of  the  parasite.  It  continues  the  reproductive 
process  by  segmentation,  and  in  time  the  former  number  of  seg- 
ments and  the  original  length  of  the  chain  are  restored.  The  ma- 
ture segment,  called  proglottides,  vary  in  size  accordingly  as  they 
are  in  a  state  of  contraction  or  relaxation.  When  relaxed,  their 
length  is  about  half  an  inch  and  breadth  one-quarter  of  an  inch. 
The  genital  organs  are  situated  on  the  margin  of  each  segment, 
a  little  posterior  to  the  middle,  and  there  is  an  alternation  in 
their  location  between  the  right  and  left  margins  in  the  chain 
of  segments.  The  uterus  lies  in  the  center  of  the  segment, 
D.  C— 14 


210  THE  DISEASES  OF  CHILDREN. 

forming  a  longitudinal  straight  line.  Several  branches  are 
given  off  from  each  side  of  the  uterus,  and  these  divide  and 
subdivide  like  the  branches  of  a  tree. 

The  male  genital  organs  lie  in  the. same  aperture  or  pore  in 
the  margin  of  the  segment  with  which  the  uterus  and  ovaries 
connect.  Abnormal  development  of  the  parasite  is  very  com- 
mon. Sometimes  two  or  more  segments  are  fused  together, 
and  often  they  are  stunted  in  their  growth.  Sometimes  they 
contain  holes,  fissures  and  flaws,  either  from  their  original 
development  or  produced  by  rupture  of  the  distended  uterus. 

The  tenia  solium  is  nearly  always  found  alone,  whence  its 
name.     The  French  call  it  ver  solitaire. 

At  the  top  of  the  head  of  this  parasite,  there  is  a  circle  of 
booklets,  and  back  of  this  circle  are  four  sucking  disks,  which 
the  worm  is  able  to  protrude  and  move  freely.  When  protruded 
they  have  the  appearance  of  small  tubercles  with  slender  pedi- 
cles. The  eggs  of  the  tenia  solium  are  globular,  with  a  diam- 
eter of  about  TTTj  of  an  inch,  and  with  thick  shells,  which  are 
striated  "  like  mosaic  work  "  by  lines  which  cross  each  other. 
It  is  estimated  that  not  less  than  5o,0(X),ooo  eggs  are  contained 
in  all  the  segments  of  a  mature  worm. 

The  tenia  saginata,  called  also  the  medio  canellata,  is  much 
larger,  stronger  and  thicker,  both  as  regards  the  head  and  the 
segments,  than  the  tenia  solium.  It  is,  however,  not  so  long, 
usually  measuring  not  to  exceed  eighteen  feet.  It  is  furnished 
with  four  strong  sucking  disks,  like  the  tenia  solium  ;  but  it 
lacks  the  circle  of  booklets  which  characterize  the  latter.  In- 
stead of  the  booklets,  the  head  is  furnished  with  a  small  frontal 
sucking  disk.  There  is  but  little  difference  in  the  sexual  appa- 
ratus of  the  two  species,  but  the  eggs  of  the  saginata  are  larger 
than  those  of  the  solium  and  are  oval  in  form.  The  former 
occurs  over  a  much  greater  area  of  the  earth's  surface  than  the 
latter. 

The  other  species  of  tenia  do  not  differ  from  these  named 
sufficiently  to  warrant  a  separate  description.  Their  symp- 
toms and  treatment  are  precisely  alike. 

Etiology. — From  what  has  already  been  said,  it  is  evident  that 
the  cause  of  worms  in  children  is  due  to  the  introduction  into 
the  system  of  either  the  ova  or  the  larva  of  the  worms  them- 
selves, and  that  when  these  have  once  found  a  lodgment  within 
the  system  and  a  suitable  soil  for  maintenance,  they  grow  and 
propagate  according  to  the  fixed  laws  of  their  species,  each 
finding  its  congenial  habitat.  Some  species,  such  as  the  ascaris 
lumbricoides,  do  not  develop  directly  from  the  egg  into  the 
adult  form  within  the  body  of  the  ultimate  bearer,  but  require 
the  intermediate  assistance  of  some  invertebrate  animal,  as  a 


WORMS.  211 

worm  or  the  larva  of  an  insect,  in  which  the  egg  is  matured,  and 
after  passing  through  certain  necessary  stages  of  metamor- 
phosis and  being  discharged,  are  received  into  the  human 
stomach  in  either  the  food  or  drink.  In  the  country,  where 
the  drinking  water  is  obtained  from  springs  or  shallow  wells,  it 
is  very  easy  for  the  water  to  become  contaminated  by  excreta 
and  to  convey  ova  or  embryos  into  the  stomachs  of  those  who 
partake  of  it.  Uncooked  fruits  and  vegetables,  such  as  salads, 
are  also  believed  to  be  common  mediums  for  their  dissemina- 
tion. A  congenial  soil  is  necessary,  however,  for  their  growth 
and  development,  and  this  is  furnished  when  the  vital  powers 
are  reduced  or  when  the  secretions  are  vitiated  by  disease.  It 
has  been  frequently  noticed  that  children  in  the  last  stages  of 
continued  fevers  often  pass  lumbrici  in  their  evacuations. 
Persistent  indigestion,  accompanied  by  irritation  or  inflamma- 
tion of  the  mucous  coat  of  the  intestines,  with  excessive  mucus 
secretion,  predisposes  to  the  generation  or  development  of 
worms.  Without  this  congenial  soil,  the  ova  or  embryos  may 
pass  harmlessly  through  the  alimentary  canal  without  effecting 
a  lodgement  and  of  course  without  propagating.  This  ac- 
counts for  the  fact  that  some  children  are  notoriously  "wormy," 
while  others  are  never  thus  troubled.  Cleanliness  has  also 
much  to  do  with  the  matter.  Those  who  go  unwashed  and 
never  clean  their  finger-nails,  or  who  live  in  almost  total  disre- 
gard of  sanitary  requirements,  are  especially  liable  to  worms. 

Symptoms  and  Diagnosis. — All  sorts  of  symptoms  have  at  one 
time  or  another  been  ascribed  to  worms.  They  have  mostly 
been  nervous,  such  as  convulsions,  epilepsy,  cramp,  choreic 
movements,  or  nightmare,  and  have  been  supposed  to  be  due 
to  some  reflex  nervous  discharge  set  going  by  the  local  irritation. 
But  it  is  very  doubtful  whether  any  are  of  diagnostic  impor- 
tance. The  presence  of  worms  can  only  be  diagnosed  with  cer- 
tainty by  finding  them  or  their  ova  in  the  evacuations  or  about 
the  anus.  The  habit  of  picking  the  nose  is  the  popular  indica- 
tion, but  it  is  often  no  indication  at  all.  Pruritus  ani  is  of  more 
value,  and  when  it  is  observed  should  always  lead  to  a  careful 
inspection  of  the  feces,  and  even  to  the  use  of  enemata  with 
the  view  to  detecting  the  worms  themselves.  Other  symptoms, 
such  as  irregularity  of  pupils,  discoloration  round  the  eyes,  tu- 
midity  of  the  abdomen  with  colicky  pains,  diarrhea,  variability 
of  appetite,  etc.,  only  need  mention  to  show  that  they  can  have 
no  special  significance,  although  they  may  probably  be  some  of 
the  many  symptoms  of  feeble  health,  impaired  digestion,  and 
irregularity  of  the  bowels,  which  are  often  present  where  worms 
abound.  The  ascaris  lumbricoides,  however,  inhabiting,  as  it 
does,  the  small  intestine,  and  often  in  large  numbers,  is  apt  to 


212  THE  DISEASES  OF  CHILDREN. 

wander  into  the  stomach,  and  is  sometimes  associated  with 
very  acute  symptoms.  Sudden  attacks  of  fever  and  vomiting 
are  apt  to  supervene,  and  to  assume  even  an  aspect  of  a  bad 
form  of  gastritis  or  of  severe  cerebral  disease.  The  round  worms 
would  seem  to  be  particularly  prone  to  induce  convulsions. 
Nor  need  we  wonder  that  such  is  the  case,  inhabiting  the  in- 
testine, as  they  may  do,  by  hundreds,  and  at  a  time  of  life  when 
the  nervous  system  has  not  yet  reached  the  stable  condition  it 
assumes  in  healthy  adult  age.  Dr.  West  has,  however,  seen 
very  severe  convulsions  with  thread  worms,  and  other  authors 
have  equally  noticed  the  liability  to  nerve  disturbances  which 
exist  with  the  tape  worm. 

Thread  worms,  collecting  in  great  numbers  in  the  rectum,  are 
apt  to  excite  local  irritation,  mucus  diarrhea,  prolapsus  ani, 
and  the  occasional  passage  of  blood  from  the  bowels.  In  the 
male  they  may  excite  priapism,  and  some  of  the  symptoms  of 
stone.  Frequent  micturition  is  a  common  symptom  of  their 
presence,  and  I  have  occasionally  noticed  hematuria  also,  and 
the  uneasy  sensations  about  the  genital  organs  may  induce  the 
habit  of  masturbation. 

In  the  female  a  purulent  discharge  from  the  vagina,  due  to 
worms  that  have  migrated  from  the  anus,  is  by  no  means  un- 
common. Worms  of  any  kind  are  liable  to  occasion  a  mucus 
diarrhea,  associated  with  a  good  deal  of  tenesmus. 

Tape  worms  give  rise  to  fewer  local  symptoms  than  either 
of  the  other  varieties  of  parasites  ;  but  they  are  often  associated 
with  progessive  and  marked  emaciation.  In  a  general  way,  it 
may  be  said  that  there  are  no  symptoms  of  worms  that  are  path- 
ognomonic— no  symptoms,  indeed,  but  may  come  equally  well 
from  any  other  cause  producing  irritation  of  the  stomach  and 
bowels.  Only  when  worms  pass  from  time  to  time,  or  when  a 
microscopical  examination  of  the  feces  has  revealed  the  pres- 
ence of  ova,  can  we  determine  positively  that  the  symptoms 
result  from  their  presence. 

An  exception  might  be  made  to  this  statement  in  the  case  of 
pin  worms — oxyuris  vermiculosis.  These  worms  can  often  be 
seen  about  the  anus,  when  this  orifice  is  subjected  to  close  in- 
spection. This  is  best  done  shortly  after  the  child  has  gone  to 
bed  for  the  night.  By  placing  the  child  on  its  elbows  and  knees, 
under  a  bright  light,  and  spreading  the  buttocks  widely  apart, 
the  worms,  if  present,  will  be  seen  wriggling  about  in  the  liveliest 
manner.  Considerable  expedition  must  be  used,  however,  for  as 
soon  as  the  worms  feel  the  cold  air  on  exposure,  they  seek  the 
folds  of  the  anus,  and  are  quickly  out  of  sight. 

Treatment. — It  is  scarcely  necessary  to  point  out  to  the  intel- 
ligent student  that  in  the  treatment  of  intestinal  parasites  we 


WORMS.  213 

are  not  dealing  with  a  simple  disturbance  of  function,  nor  with 
any  of  the  ordinary  problems  of  pathology. 

It  would  be  the  merest  folly  to  treat  the  symptoms  produced 
by  worms,  while  leaving  the  worms  themselves  undisturbed. 
The  question  of  remedies,  then,  is  outside  the  pale  of  medical 
dogmas,  and  is  purely  one  pertaining  to  toxicology.  When 
treating  a  patient  for  worms,  the  homeopathic  physician  is  com- 
pelled to  lay  aside  his  favorite  shibboleth  and  accept  the  empir- 
ical treatment  which  has  been  born  of  necessity  and  cultured 
by  experience.  Much  harm  has  been  done  by  resorting  too 
early  to  vermicides  under  a  misinterpretation  of  symptoms, 
when  a  careful  and  tentative  exhibition  of  the  indicated  home- 
opathic remedy  would  have  been  far  better.  Such  remedies  in 
proper  attenuation  should  always  be  given  first  in  the  absence  of 
unmistakable  signs  of  worms,  and  after  this,  if  the  symptoms 
still  persist,  the  appropriate  anthelmintic  should  be  given. 

It  should  be  borne  in  mind,  however,  that  even  after  the  par- 
asites have  been  expelled,  a  condition  of  the  system  may  remain 
that  renders  it  possible  for  the  worms  to  develop  again,  and 
this  condition  must  be  changed  before  a  complete  and  radical 
cure  can  be  looked  for.  In  other  words,  it  is  not  alone  sufficient 
to  remove  the  worms  from  the  intestinal  canal ;  we  must  in 
addition  so  alter  the  soil  as  to  render  it  impossible  for  others  to 
propagate. 

Hahnemann  was  not  the  only  one  of  the  older  writers  who 
believed  that  a  state  of  system  favorable  to  the  propagation  of 
intestinal  parasites  was  necessary  to  their  production,  and  that 
that  state  or  condition  was  removable  by  medicinal  agents. 

Brenner,  who  has  the  reputation  of  being  the  most  celebrated 
helminthologist  of  his  time,  designated,  under  the  name  of 
diathesis  verminosa,  a  condition  of  the  alimentary  canal  accom- 
panied by  disorders  of  nutrition  and  digestion,  in  consequence 
of  which  material  accumulated  in  the  intestine  which  was  fav- 
orable to  the  production  of  worms.  It  was  even  held  by  such 
distinguished  investigators  as  Rilliet  and  Barthez  that  this 
worm  diathesis  could  exist  without  the  presence  of  worms. 

Now,  however,  thanks  to  the  exact  scientific  work  done  by 
patient  investigators,  accompanied  by  experiments  on  animals 
and  man,  the  life  history  of  most  of  the  intestinal  parasites,  and 
the  part  which  they  play  in  the  production  of  disease,  have 
been  put  on  a  firm  and  scientific  basis. 

As  the  different  varieties  of  worms  require  different  remedies 
to  effect  their  expulsion,  we  shall  speak  of  them  seriatim. 

Ascaris  Lumbricoides. — For  these  round  worms  our  most  effi- 
cient remedy  issantonine,  which  is  the  active  principle  of  cina, 
or  artemisia  santonica.     It  should  be  given  in  the  evening  at 


214  THE  DISEASES  OF  CHILDREN. 

bedtime,  in  doses  of  from  one  to  three  grains  in  powder,  in  the 
form  of  troches  or  capsules,  or  as  it  is  nearly  tasteless,  it  may 
be  spread  on  bread-and-butter.  It  should  be  followed  in  the 
morning  by  castor  oil  or  some  other  efficient  laxative.  Dr. 
Cowperthwaite  says  that  he  has  secured  all  of  the  benefits  of 
santonine  by  giving  the  first  or  second  decimal  trituration  four 
times  daily  for  three  or  four  days.  He  states  that  when  given  in 
this  way  the  drug  does  not  produce  its  objectionable  symptoms, 
viz.,  disturbed  vision,  red  urine,  etc.,  which  so  frequently  fol- 
low the  administration  of  large  doses.  It  has  been  our  own 
practice  to  combine  with  the  santonine,  as  above  indicated,  a 
powder  of  the  second  decimal  trituration  of  mere.  cor.  sub., 
which  obviates  the  necessity  of  giving  castor  oil  afterwards. 

Spigelia,  or  pink  root,  is  also  an  excellent  vermicide,  and 
may  be  given  in  doses  of  from  ten  to  thirty  minims,  of  the 
fluid  extract.  It  is  mostly  used  in  an  officinal  preparation, 
combined  with  senna. 

Cina. — This  is  the  crude  drug,  artemisia  santonica,  of  which 
santonine  is  the  active  principle.  It  is  of  all  vermicides  the 
most  valuable,  especially  for  the  round  and  thread  worms.  It 
is  also  quite  homeopathic  to  the  existing  morbid  condition 
whose  symptoms  are  usually  attributed  to  worms,  whether 
they  are  present  or  not,  and  will  remove  their  symptoms  while 
acting  as  a  vermicide  at  the  same  time.  Special  indications 
for  its  exhibition  will  be  given  under  the  head  of  General  Thera- 
peutics, at  the  end  of  the  chapter.  It  should  be  administered 
in  drop  doses  of  the  tincture  in  a  little  water  or  on  sugar  every 
three  or  four  hours. 

Oxyuris  Vermicularis. — For  this  variety  of  worms,  medicines 
administered  by  the  mouth  are  of  but  little  account.  As  has 
been  already  pointed  out,  their  habitat  is  in  the  rectum  and 
about  the  anus.  For  this  reason  they  are  generally  reached 
most  effectually  by  means  of  injections.  Common  salt  and 
water  is  oftentimes  all  that  is  necessary.  Infusions  of  fresh 
garlic  injected  into  the  rectum  for  a  few  nights  at  bedtime  we 
have  found  very  effectual.  If  used  under  the  physician's 
personal  supervision,  an  enema  of  bichloride  of  mercury,  in  the 
strength  of  one  grain  to  four  ounces  of  water,  is  a  sure  cure. 
It  should  not  be  repeated,  and  should  be  followed  after  a  few 
minutes  by  an  injection  of  plain  cold  water.  Anointing  the 
anus,  and  the  labia  vaginae  when  necessary,  with  sweet  oil  or 
vaseline,  is  of  benefit. 

Tape  Worms. — In  the  treatment  of  tape  worms,  great  pa- 
tience and  persistence  are  often  necessary  to  secure  the  head. 
Unless  this  is  secured  the  worm  will  grow  again,  necessitating 


TAPE    WORMS.  215 

a  repetition  of  the  treatment.  As  it  takes  from  ten  to  twelve 
weeks  for  the  worm  to  develop  its  full  length,  it  is  often  impos- 
sible to  tell  before  this  length  of  time  has  elapsed  whether  the 
treatment  has  been  successful  or  not.  It  must  be  borne  in 
mind  that  all  of  the  remedies  used  for  the  expulsion  of  tape 
worms  are  more  or  less  poisonous  in  their  nature,  and  irritating 
to  the  stomach  and  bowels.  They  should  never  be  used,  there- 
fore, without  there  is  good  and  sufficient  ground  to  believe 
them  necessary. 

Before  administering  the  tenicide,  the  patient  should  be 
placed  on  a  low  diet  for  a  few  days,  avoiding  such  articles  of 
food  as  are  digested  in  the  small  intestines,  and  only  eating 
beef-tea,  chicken-soup,  milk,  toast,  or  some  light  food  which 
leaves  little  residuum.  German  physicians  put  their  patients  on 
a  diet  of  onions,  garlic  and  salt-herring,  for  the  reason  that 
these  articles  are  known  to  be  obnoxious  to  the  worm.  The 
medicine  may  then  be  administered,  and  after  a  few  hours  an 
active  purgative  given  to  expel  the  dead  parasite.  In  case  the 
head  is  not  discharged,  there  is  no  certainty  of  the  success  of 
the  treatment,  but  further  means  for  its  removal  should  not  be 
employed  until  fragments  of  the  worm  are  again  discharged. 

Male  fern  or  filix  mas,  is  the  oldest  and  probably  most  pop- 
ular tenicide.  It  is  best  administered  in  capsules  containing 
one-half  drachm  of  the  ethereal  extract.  The  oil  may  also  be 
given  in  half-drachm  doses,  in  mucilage  with  milk. 

The  bark  of  the  pomegranate  root  {Punica  granatuin)  is  an  ex- 
cellent tenicide.  The  fresh  bark  only  should  be  used.  About 
one  to  one  and  a  half  ounces  should  be  boiled  in  a  pint  and  a 
half  of  water  until  the  quantity  is  reduced  one-half,  this  amount 
being  taken  in  three  doses  within  an  hour. 

Kuckenmeister  strongly  advises  the  addition  of  ten  or  fifteen 
grains  of  the  ethereal  extract  of  male  fern.  The  tannate  and 
sulphate  of  pelletierin,  the  active  principle  of  the  pomegranate, 
have  both  been  successfully  used  to  remove  the  tapeworm. 

Kousso,  the  flowers  and  tops  of  Brayera  anthelmintica,  a  tree 
of  Abyssinia,  a  country  where  the  tape  worm  abounds,  is  con- 
sidered an  effective  tenicide,  and  is  much  used  for  the  species 
there  prevalent.  It  has  also  been  used  with  success  in  Europe 
and  America.  It  may  be  given  in  doses  of  from  one  to  two 
drachms  of  the  powder.  Heller  prefers  to  give  it  in  compressed 
balls  or  disks  coated  with  gelatine.  He  considers  three  drachms 
necessary  for  the  tenia  solium,  and  five  drachms  for  the  tenia 
saginata.  The  balls  or  disks  should  be  placed  on  the  back  part  of 
the  tongue  and  swallowed  alone,  or  by  the  aid  of  some  coffee. 
After  this,  the  tendency  to  vomiting  should  be  resisted,  with 
the  assistance  of  lemon-juice,  bits  of  ice  swallowed,  and  by 


216  THE  DISEASES  OF  CHILDREN. 

maintaining  the  recumbent  position.  He  advises  an  ounce  of 
castor  oil  two  hours  later,  to  expel  the  worm  speedily  and  en- 
tire. Koussin,  an  alcoholic  extract,  is  now  used  by  some  in  ten 
to  twenty-grain  doses,  instead  of  the  crude  drug. 

Kamala,  the  glandular  powder  and  hairs  from  the  capsules 
of  the  rottlera  tinctoria,  is  an  efficient  and  not  unpleasant  teni- 
cide.  It  may  be  given  in  doses  of  from  one  to  two  drachms, 
prepared  in  a  gum-arabic  emulsion,  and  repeated  every  three 
hours  if  necessary.  No  purgative  is  required  to  follow.  If 
two  or  three  doses  do  not  prove  effectual,  add  about  one-half 
drachm  of  the  oil  of  male  fern,  and  repeat. 

Pepo  semen,  an  emulsion  of  pumpkin-seeds,  is  ranked  in  this 
country  as  one  of  the  best  tenifuges.  It  possesses  the  advan- 
tage of  producing  no  unpleasant,  injurious  effects.  The  emul- 
sion is  prepared  by  rubbing  up  about  two  ounces  of  the  fresh 
seeds  in  a  mortar  with  a  pint  of  water,  and  straining  through  a 
cloth.  To  this  ten  to  fifteen  minims  of  sulphuric  ether  should 
be  added,  and  the  whole  quantity  taken  at  one  dose,  in  the 
morning  on  an  empty  stomach.  If  the  first  dose  is  not  effec- 
tual, it  may  be  repeated  each  morning  for  several  days. 

Turpentine  is  an  efficient  tenicide,  but  its  unpleasant  taste 
and  the  ill  effects  following  its  use  have  prevented  its  general 
employment,  save  in  cases  which  have  resisted  other  methods 
of  treatment.  It  may  be  given  in  one  to  two  drachm-doses 
every  half-hour  until  an  ounce  is  taken.  Bartholow  advises 
uniting  with  it  an  equal  amount  of  castor  oil.  It  is  probable 
that  any  of  the  medicines  before  mentioned  are  equally  effec- 
tual, and  less  injurious  to  the  system. 

General  Therapeutic  Indications  for  Intestinal 
Worms. — In  addition  to  the  methods  suggested  for  the  destruc- 
tion and  removal  of  intestinal  worms,  our  Materia  Medica  af- 
fords a  number  of  remedies  which  have  been  proved  valuable 
for  the  relief  of  symptoms  associated  with  the  presence  of  these 
parasites  or  which  remain  after  their  removal. 

Cina  is  our  most  important  remedy.  It  not  only  covers  the 
range  of  symptoms  most  often  found  in  connection  with  the 
presence  of  round  or  thread  worms,  but  containing  santonine 
as  its  active  principle,  it  is  practically  a  vermicide,  and  frequently 
the  only  remedy  required  for  the  removal  of  the  parasites  and 
the  symptoms  they  may  have  produced.  Its  chief  indications 
are :  child  irritable  and  cross ;  has  dark  rings  around  the  eyes, 
and  a  sickly  expression  ;  white  and  bluish  around  the  mouth ; 
tossing  about  in  sleep,  with  sudden  cries  ;  boring  in  the  nose 
with  the  finger  ;  grinding  the  teeth  at  night ;  great  hunger,  or 
loathing  of   food ;    nausea  and  vomiting ;   abdomen  hard  and 


INTESTINAL    WORMS.  217 

distended  ;  twisting,  colicky  pains  ;  itching  of  the  anus  ;  turbid 
urine  ;  dry,  hacking  cough,  which  causes  gagging:  twitching  of 
the  muscles,  and  convulsive  motion  of  the  head  and  limbs; 
fever,  usually  intermittent  or  remittent  in  its  character. 

Ignatia. — Especially  in  mild,  nervous  children.  Itching  and 
crawling  at  the  anus  and  in  rectum,  as  from  thread  worms  ; 
prolapsus  ani ;  epileptiform  convulsions. 

Mercurius. — Excessive  hunger;  salivation  ;  fetid  odor  from  the 
mouth  ;  abdomen  hard,  distended  and  painful ;  glandular  swell- 
ings ;  will  sometimes  cause  discharge  of  ascarides  or  of  lumbrici 
without  other  aid. 

Aconite. — Worm  fever.  Excessive  restlessness,  face  red  and 
pale  alternately  ;  loathing  of  food  ;  intolerable  nightly  tingling 
and  itching  at  the  anus  as  from  thread  worms. 

Spigelia. — Nausea  every  morning,  better  after  eating ;  squint- 
ing ;  sensation  of  a  worm  rising  in  the  throat,  better  after  eat- 
ing; itching  and  tingling  in  anus  and  rectum. 

Sulphur. — Especially  after  other  remedies  have  failed  ;  exces- 
sive, ravenous  hunger,  though  the  stomach  feels  full  and  dis- 
tended after  eating  but  little ;  nausea  before  meals,  and  gone^ 
faint  feeling  about  1 1  A.  M, ;  abdomen  distended ;  itching  and 
crawling  in  rectum  and  anus ;  turbid  urine ;  emaciation  and 
debility. 

Calcarea  carbonica. — In  leuco-phlegmatic  children,  especially 
where  there  seems  to  be  a  hereditary  predisposition  to  worms ; 
abdomen  hard  and  much  distended  ;  children  of  a  scrofulous 
habit. 

Consult  also  Terebinthina,  Stannum,  Cinchona,  Ferrum,  Saba- 
dilla,  Urtica  urens,  Teucrium  (thread  v^oxm),  Antimonitim  crud. 

For  the  symptomatology,  diagnosis  and  treatment  of  other 
forms  of  intestinal  parasites  than  those  here  mentioned,  includ- 
ing trichina  spiralis,  the  reader  is  referred  to  works  on  general 
practice. 


CHAPTER   VII. 

INTESTINAL   OBSTRUCTION. 

Intussusception — Definition. — Intussusception,  or  invagi- 
nation of  the  bowels,  occurs  when  one  portion  of  the  bowel 
passes  into  another  adjoining  portion.  It  is  not,  properly- 
speaking,  a  disease,  but  rather  an  accident  and  therefore  belongs 
more  to  works  on  surgery  than  medicine.  It  is,  however,  essen- 
tial that  the  student  of  pedology  should  be  familiar  with  its 
symptoms  and  nature,  for  it  is  one  of  the  most  painful  and 
dangerous  maladies,  and  everything  pertaining  to  its  relief 
depends  on  its  early  recognition. 

Fortunately,  it  is  of  rare  occurrence,  especially  in  private 
practice.  Rilliet  and  Barthez  have,  however,  recorded  twenty- 
five  cases  as  occurring  in  their  experience  and  Dr.  J.  Lewis 
Smith  has  tabulated  the  history  of  fifty-two  cases.  Nearly 
one-half  of  these  cases  were  under  six  months  of  age.  Leich- 
tenstein,  who  has  compiled  statistics  of  four  hundred  and 
seventy-three  cases,  says  :  "  Half  of  all  invaginations  occur  dur- 
ing the  first  ten  years.  The  first  year,  after  the  third  month,  is 
remarkable  for  a  special  frequency — one-fourth  of  all  intus- 
susceptions." No  case  under  three  months  is  recorded  by 
either  of  these  observers. 

Some  curious  facts  relating  to  sex  and  previous  condition  of 
health  are  brought  out  by  the  statistics  furnished  by  these  gen- 
tlemen. Of  the  twenty- five  cases  collated  by  Rilliet  and  Barthez 
all  but  three  were  boys,  and  of  thirty-four  cases  of  J.  Lewis 
Smith's  fifty-two,  twenty-three,  or  two-thirds,  were  boys. 
Among  the  latter  collection  one-half  of  the  number  had  been 
in  previous  good  health  when  the  accident  occurred,  while  the 
other  half  had  been  more  or  less  ailing.  Most  of  the  latter  had 
been  suffering  from  diarrhea,  dysentery  or  constipation,  or 
diarrhea  alternating  with  constipation. 

Dr.  Smith  therefore  concludes  that  the  two  opposite  condi- 
tions, namely,  constipation  and  the  diarrheal  maladies,  so  often 
precede  the  displacement  that  they  must  be  regarded  as  com- 
mon causes.  He  further  says  :  "  The  great  liability  to  intus- 
susception in  infancy  is  due  partly  to  the  anatomical  character 
of  the  intestine  in  this  period  of  life,  and  partly,  doubtless,  to 
the  fact,  that  there  are  more  frequent  irregularities  in  the 
(218) 


INTUSSUSCEPTION.  219 

intestinal  movements  than  in  older  children.  In  the  infant  the 
walls  of  the  intestines  are  thin,  the  mucous  and  muscular  coats 
and  the  connective  tissue  being  much  less  developed  than  in 
those  that  are  older.  The  mesentery  and  meso-colon  have  also 
greater  depth  as  compared  with  the  same  in  other  periods  of 
life,  except  the  meso-colon  at  the  points  where  it  passes  over 
the  kidneys,  in  which  places  it  is  very  short  or  even  in  some 
cases  nearly  absent.  Moreover,  the  space  occupied  by  the  large 
intestine,  in  which  part  of  the  digestive  tube  intussusception 
commonly  occurs,  is  much  shorter  relatively  to  the  length  of 
the  intestine,  than  in  those  that  are  older.  In  about  thirty 
measurements  which  I  have  made  of  the  length  of  the  large 
intestine  and  the  space  occupied  by  it,  the  latter  was  found  on 
the  average  about  one-third  that  of  the  former,  which  of  course, 
necessitates  doubling  of  the  intestine  on  itself.  These  peculiar- 
ities of  structure  in  the  infant  obviously  favor  the  occurrence 
of  intussusception." 

The  direction  of  an  invagination  is  always  downward  in  the 
direction  of  the  normal  peristalsis ;  that  is,  that  portion  of  the 
intestine  which  receives  the  other  is  always  on  the  lower  or 
anal  side. 

In  the  majority  of  cases  of  intussusception  occurring  in 
infancy  and  childhood,  the  seat  of  trouble  is  near  the  ileo-cecal 
valve.  Either  the  ileum  is  invaginated  in  the  colon  or  the  first 
part  of  the  colon  is  invaginated  in  the  part  succeeding  it.  In 
rare  instances  the  intussusception  takes  place  in  the  small 
intestine.  Sometimes  there  is  so  little  constriction  of  the  incar- 
cerated portion  of  the  bowel  that  it  remains  pervious.  In  these 
cases  life  may  be  maintained  for  weeks  or  months  without  any 
material  change  in  the  displacement,  but  death  ultimately  takes 
place  from  exhaustion. 

Symptoms. — The  symptoms  of  intussusception  are  very  simi- 
lar to  those  of  strangulated  hernia.  Instead  of  the  obstinate 
constipation,  however,  which  marks  the  latter  malady,  we  have 
in  acute  cases,  great  tenesmus  with  blood  and  bloody  mucus, 
extruded  from  the  anus. 

In  some  part  of  the  abdomen,  corresponding  to  the  seat  of 
the  invagination,  we  have  an  elongated,  doughy  tumor.  Very 
soon  after  this  tumor  is  found  we  have  vomiting,  first  of  food, 
if  any  has  been  recently  taken,  and  after  that  mucus  and  blood. 
Stercoraceous  vomiting  occurs  in  only  one-fourth  of  the  cases. 

The  pain  is  very  great  and  is  accompanied  with  constant 
tenesmus.  There  is  a  sudden  supervention  of  the  symptoms 
of  collapse,  such  as  pallor,  sunken  eyes  and  rapid  pulse.  In 
chronic  cases  all  of  these  symptoms  may  be  absent.  Goodhart 
tells  of  a  case  that  occurred  in  his  practice,  in  which  there  was 


220  THE  DISEASES  OF  CHILDREN. 

an  utter  absence  of  all  signs  of  intussusception  before  death, 
and  the  invagination  of  the  bowel  was  only  discovered  post 
mortem.  Usually,  however,  the  symptoms  are  well  marked. 
At  least,  there  is  no  mistaking  the  fact  that  the  child  is  desper- 
ately ill.  The  onset  of  the  acute  symptoms  is  sudden.  Thirst  is 
nearly  always  present  and  tenesmus  is  rarely  absent.  The  tem- 
perature is  at  first  normal,  but  very  soon  becomes  sub-normal. 

In  a  large  proportion  of  cases,  a  careful  palpation  of  the  ab- 
domen reveals  a  sausage-shaped,  soft,  elastic,  and  doughy 
tumor,  which  at  first  is  not  painful  to  the  touch,  but  soon  be- 
comes so.  It  varies  in  size  from  an  ^^^  upward,  but  is  rarely 
more  than  a  few  inches  long.  Sometimes  the  tumor  is  so  low 
down  in  the  colon  that  it  can  be  felt  by  the  finger  inserted  in 
the  rectum.  In  acute  cases  the  diagnosis  is  easy,  but  in  chronic 
cases  it  may  be  attended  with  extreme  difficulty.  When  the 
diagnosis  is  once  made  there  is  nothing  to  be  gained,  but  much 
to  lose,  by  procrastination.  The  most  energetic  measures 
should  be  instituted  at  once. 

Prognosis. — In  acute  cases,  where  the  onset  of  symptoms  is 
sudden  and  severe,  the  treatment  is  usually  unsuccessful,  and  in 
from  twenty-four  to  thirty-six  hours,  the  child  dies.  But 
enough  cases  have  terminated  favorably  under  treatment  to 
furnish  ground  for  a  certain  amount  of  hope.  In  chronic  cases 
strangulation,  as  a  rule,  does  not  occur,  and  the  case  may  go  on 
for  weeks  or  months  with  only  ill-defined  symptoms.  The  pain 
at  first  is  paroxysmal,  and  there  may  be  long  intervals  during 
which  it  is  entirely  absent.  Vomiting  may  be  present  or  not. 
At  any  time,  however,  these  chronic  cases  may  take  on  acute 
symptoms,  or  on  the  other  hand,  may  in  time  terminate  favor- 
ably even  without  treatment. 

Dr.  Hern  calls  attention  to  a  valuable  diagnostic  point  in 
this  connection,  viz.  :  in  chronic  invagination  the  tumor  moves 
its  position  and  gradually  advances,  while  the  tumor  resulting 
from  fecal  impaction  remains  stationary. 

Treatment. —  It  is  only  in  chronic  cases,  not  attended  by  ur- 
gent symptoms,  such  as  vomiting,  acute  pain,  and  threatened 
collapse,  that  medicine  can  be  of  any  service.  But  in  these 
chronic  cases,  remedies  calculated  to  control  spasms  and  allay 
irritability,  may  prove  useful.  These  remedies  are  mainly  Bel- 
ladonna, Gelsemium,  Colocynth,  Nux  vomica,  and  Hyoscyavtus. 
No  medicine  having  the  effect  to  stimulate  peristalsis  is  per- 
missible under  any  circumstances. 

In  acute  cases  the  treatment  must  be  principally  mechanical 
or  surgical.  Gentle  massage  of  the  abdomen  may  sometimes 
succeed  in  disengaging  the  incarcerated  part ;  but  no  great 
amount  of  time  should  be  spent  in  the  employment  of  measures 


IN  T  USS  US  CEP  TION.  221 

like  this,  which  are  so  manifestly  unreliable.  Our  main  depend- 
ence, this  side  of  laparotomy,  must  be  on  injections  of  oil  or 
water,  or  insufflation  of  the  bowel  by  means  of  gas  or  air.  Both 
of  these  measures  have  been  used  successfully,  and  both  appeal 
to  reason  and  common  sense.  There  is  a  difference  of  opinion 
as  to  which  is  better,  and  the  record  of  successful  cases  shows 
that  each  has  succeeded  after  the  other  has  failed. 

In  using  water  enemata,  the  child  should  rest  on  a  pillow,  or 
on  the  nurse's  lap,  with  the  hips  elevated  at  an  angle  of  45°. 
The  water  should  be  warm,  and  should  be  gently  poured  into 
the  bowel  by  means  of  a  fountain  syringe  held  above  the  patient 
sufficiently  high  to  secure  a  hydrostatic  pressure  of  five  or  six 
pounds  to  the  square  inch,  i.  e.,  twelve  to  fifteen  feet.  Experi- 
ments on  the  cadaver  have  demonstrated  that  the  normal  colon 
will  bear  a  pressure  of  eight  or  nine  pounds  without  rupturing  ; 
but  it  must  be  borne  in  mind  that  in  a  case  of  intussusception 
twenty-four  hours,  or  less,  may  produce  a  gangrenous  state  of 
the  bowel,  and  its  resistance  be  thereby  greatly  lessened.  The 
water  should  be  allowed  to  flow  steadily  and  gently  into  the 
gut,  and  not  in  a  sudden  or  spasmodic  jet. 

While  the  enema  is  being  given,  the  abdomen  should  be 
manipulated  by  an  assistant,  so  as  to  urge  the  stream  of  water 
into  the  constriction.  It  may  be  necessary  in  some  cases  to  resort 
to  anesthesia  to  secure  a  thorough  trial  of  this  proceeding.  In 
case  of  failure,  the  operation  should  be  repeated  again  after  a 
few  hours'  rest.  In  using  insufflation  of  air,  a  common  bellows 
will  answer,  using  the  nozzle  of  a  Richardson  syringe  and  a 
rubber  tube.  The  nozzle  of  the  syringe  will  have  to  be  closely 
packed  about  the  anus,  in  order  to  prevent  the  outward  escape 
of  air.  There  is  not  so  much  danger  of  rupturing  the  bowel 
with  air  or  gas  as  with  water,  but  it  may  be  well  to  use  some 
caution,  lest  such  an  accident  might  happen.  There  are  various 
appliances  for  generating  gas  for  use  in  such  emergencies  as 
this,  to  be  had  of  the  instrument-makers  ;  but  a  description  of 
them  is  not  deemed  necessary. 

When  these  measures  have  failed  to  relieve  the  invagination, 
there  is  but  one  resource  left,  and  that  is  laparotomy.  The 
published  statistics  of  this  operation  on  children  are  far  from  en- 
couraging, for  they  do  not  bear  well  the  shock  which  is  unavoid- 
able in  opening  the  abdominal  cavity.  But  cases  of  recovery 
after  laparotomy  has  been  performed  have  been  recorded,  even 
in  children  as  young  as  six  months;  and  after  other  measures 
have  failed,  the  case  is  always  so  desperate  that  even  a  forlorn 
hope  is  better  than  no  hope  at  all. 

The  method  to  be  pursued  in  the  performance  of  the  opera- 
tion belongs  properly  to  works  on  surgery. 


CHAPTER   VIII. 

DENTITION. 

The  development  of  the  teeth  and  their  eruption  through 
the  gums  marks  one  of  the  epochs  or  stages  in  the  progress  of 
of  the  infant  toward  maturity,  and  is  the  only  one  that  is  accom- 
panied more  often  than  otherwise,  with  pain  or  general  consti- 
tutional disturbance.  It  is  not  to  be  understood  that  dentition 
is  in  itself  a  morbid  process  or  that  it  is  always  accompanied  by 
pathological  symptoms.  On  the  contrary,  the  process  is  a 
purely  physiological  one,  and  in  exceptional  cases  proceeds 
from  beginning  to  end  without  symptoms  of  an  abnormal  char- 
acter. But  these  exceptions  are  rare.  As  a  general  thing,  for 
some  time  before  the  eruption  of  the  teeth  there  is  more  or  less 
restlessness,  some  slight  fever,  irritability  of  the  stomach,  and 
diarrhea.  It  does  not  always  follow  that  such  disturbances  as 
these  just  mentioned  are  altogether  due  to  the  teeth,  for  the 
teething  period  is  one  of  great  general  activity,  and  other  por- 
tions of  the  organism  are  undergoing  change  and  evolution,  as 
well  as  the  gums.  Towards  the  end  of  the  first  year  of  life,  the 
follicular  apparatus  of  the  intestines  is  undergoing  increased 
development,  the  cerebro-spinal  system  is  passing  through  a 
stage  of  rapid  growth  and  high  functional  activity,  and  most  of 
the  organs  and  tissues  of  the  body  are  in  a  state  of  active 
change.  The  evolution  of  the  teeth  is  not,  therefore,  a  solitary 
instance  of  developmental  progress,  but  corresponds  to  a  sim- 
ilar activity  of  growth  in  other  parts.  It  is  not  at  all  strange 
that  a  period  of  such  rapid  transitions  should  be  also  a  period 
of  exceptional  susceptibility.  And  thus  we  find  it  to  be.  Dur- 
ing this  period  morbid  impressions,  which  later  on  would  soon 
be  overcome,  are  now  more  lasting  and  serious ;  and  functional 
disturbances,  which  ordinarily  would  soon  rectify  themselves, 
easily  drift  into  incurable  maladies. 

The  first  dentition — or,  to  speak  more  accurately,  the  first 
dental  epoch — begins  at  about  the  middle  of  the  first  year  and 
ends  towards  the  beginning  of  the  third  year,  or  when  the  infant 
is  two  years  or  two-and-a-half  years  old.  The  progress  of  den- 
tition, however,  is  subject  to  many  deviations.  In  exceptional 
cases,  the  first  of  the  milk  teeth  appear  much  earlier  than  the 
time  above  mentioned,  and  cases  are  on  record  of  children  born 
(222) 


DENTITION.  223 

with  teeth.  In  other  cases  the  dental  epoch  is  delayed,  and 
the  entire  set  of  milk  teeth  is  not  erupted  until  the  child  is  five 
or  six  years  old. 

Under  normal  conditions,  the  first  dentition  begins  at  about 
the  fifth  or  sixth  month,  and  continues  with  occasional  pauses 
until  the  full  twenty  teeth  have  made  their  appearance.  The 
teeth  are  inclined  to  erupt  in  pairs,  those  of  the  lower  jaw  pre- 
ceding those  of  the  upper  by  a  brief  interval.  Occasionally  in 
precocious  children  a  considerable  number  of  teeth  are  erupted 
together,  or  so  closely  together  as  to  be  a  source  of  danger. 

This  happens  often  in  children  in  the  best  of  health,  plump, 
large  and  rosy,  but  is  not  devoid  of  danger.  Their  plethora  and 
precocity  are  a  misfortune,  for  an  infant  at  this  early  age,  no 
matter  how  strong  and  healthy,  can  bear  only  a  certain  amount 
of  nervous  strain. 

Ordinarily  the  milk  teeth  make  their  appearance  in  the  fol- 
lowing order : 

Between  the  fifth  and  seventh  months  after  birth  the  two 
central  incisors  of  the  lower  jaw  erupt,  at  or  about  the  same  time. 

Between  the  seventh  and  ninth  months,  the  two  upper  cen- 
tral incisors  appear,  followed  shortly  by  the  two  lateral  incisors. 

Between  the  ninth  and  twelfth  months,  the  two  inferior  lat- 
eral incisors,  the  two  upper  anterior  molars  ;  and  in  the  two 
succeeding  months,  the  two  lower  anterior  molars  appear. 

Between  the  fifteenth  and  twentieth  months,  the  four  canine 
teeth  erupt.  Between  the  the  twentieth  month  and  the  middle 
of  the  second  year,  the  four  posterior-  molars  appear. 

The  eruption  of  the  twenty  milk  teeth,  or  as  they  are  some- 
times called,  the  deciduous  teeth,  is  now  complete,  and  no 
more  teeth  make  their  appearance  until  the  fifth  or  sixth  year, 
when  these  teeth  fall  out  or  are  forced  out,  to  make  place  for 
the  permanent  set.  The  temporary  teeth  drop  out  in  about 
the  same  order  as  they  made  their  appearance. 

While  the  order  above  given  is  that  which  is  usually  adhered 
to,  it  is  not  uncommon  for  this  normal  sequence  to  be  violated. 
The  upper  incisors  sometimes  erupt  first,  and  when  such  is 
the  case,  their  appearance  is  usually  somewhat  delayed.  In 
rare  instances,  the  molars  or  canines  precede  the  incisors,  a 
posterior  molar  erupts  before  a  canine,  or  a  canine  precedes  an 
anterior  molar. 

With  some  superstitious  but  otherwise  intelligent  people, 
the  eruption  of  the  upper  incisors  first  is  considered  a  bad 
omen.  Among  some  of  the  tribes  of  Central  Africa,  a  child 
that  cuts  the  upper  teeth  first  is  believed  to  be  maiko  (unlucky), 
and  certain  to  bring  death  into  the  family.  Such  a  child  is, 
therefore,  sold  to  the  Arabs. 


224  THE  DISEASES  OF  CHILDREN. 

Symptoms  and  Disorders  of  Teething.— Shortly  before 
the  teeth  begin  to  make  their  appearance,  there  is  a  noticeable 
increase  of  saliva,  which  dribbles  from  the  mouth  and  is  called 
drooling.  At  the  same  time,  the  infant  exhibits  an  uneasiness 
of  manner,  which  is  referable  to  the  gums,  and  which  is  par- 
tially relieved  by  rubbing  them.  In  pursuance  of  this  object, 
the  child  "munches"  with  his  jaws,  sucks  his  lips  and  gives 
other  evidences  of  uneasiness.  His  sleep  is  disturbed  and  dur- 
ing the  day  frequent  contractions  of  the  brow  give  indications 
of  pain. 

Examination  of  the  mouth  reveals  the  source  of  discomfort. 
The  gums  are  found  swollen  and  cushiony,  and  shortly  before 
the  tooth  appears  are  hot  and  tense.  At  this  time  friction, 
which  before  was  pleasant,  becomes  very  painful.  The  gum  is 
evidently  tender,  which  tenderness,  however,  subsides  as  soon 
as  the  tooth  is  through. 

The  pyrexia  of  teething  is  very  irregular,  and  subject  to  rapid 
variations.  It  is  often  higher  in  the  morning  than  at  night  and 
fluctuates  during  the  day. 

These  symptoms  do  not  always  accompany  immediately  the 
eruption  of  a  tooth,  but  may  precede  it  by  days  or  even  weeks. 
Nor  are  the  symptoms  steady  and  persistent.  They  come  and 
go — waxing  and  waning  in  severity,  and  frequently  subsiding 
altogether  for  a  time,  so  that  the  child  passes  through  alternate 
periods  of  suffering  and  ease  before  the  tooth  finally  erupts. 
The  sense  of  discomfort,  of  pain  and  general  disturbance  which 
the  infants  feel,  is  not  usually  so  great  at  the  time  the  tooth 
pierces  the  gum,  as  it  is  when  the  tooth  is  forcing  its  way  upward 
through  the  dental  processes  which  hold  it  securely  in  the  jaw. 

Complications. — The  symptoms  just  described  are  to  be 
regarded  as  the  natural  accompaniment  of  dentition,  and  in 
themselves  do  not  indicate  anything  about  the  process  of  an 
abnormal  character.  But  oftentimes  these  symptoms  are  but 
the  precursor  of  others  more  serious  in  their  nature,  and  which 
are  to  be  considered  as  accidental  complications.  They  arise 
from  ordinary  causes  of  derangement  acting  upon  a  body  al- 
ready in  a  state  of  irritation  and  fever,  and  therefore  peculiarly 
susceptible  to  their  malign  influence. 

These  complications  are  for  the  most  part  stomatitis,  repeated 
vomiting  and  diarrhea,  gastritis,  cough  from  pulmonary  catarrh, 
otitis,  various  forms  of  skin  disease,  and  certain  disorders  of 
the  nervous  system,  such  as  squinting,  tonic  contractions  of 
muscles,  convulsions,  etc. 

Some  children  at  this  time  are  remarkably  subject  to  colds, 
and  pulmonary  catarrh  is  a  common  complication  of  teething, 


PREMATURE  DECAY  OF  TEETH.  225 

and  when  present  should  never  be  neglected,  for  the  reason 
that  it  may  easily  lead  to  a  severe  bronchitis  or  broncho-pneu- 
monia. If  the  teeth  are  cut  in  rapid  succession,  a  looseness  of 
the  bowels  is  apt  to  prevail  to  a  greater  or  less  degree  during 
the  whole  period  of  dentition.  If  the  looseness  remains  con- 
fined within  moderate  bounds,  it  may  do  no  harm  ;  but  on  the 
contrary  have  a  salutary  effect  in  relieving  the  irritation  and 
tension  of  the  nervous  system.  It  should  not,  however,  be 
allowed  to  transcend  certain  bounds,  especially  in  the  summer 
time,  for  the  reason  that  a  simple  and  innocent  diarrhea  may 
be  quickly  changed  into  the  inflammatory  form  from  some 
indiscretion  in  eating  or  sudden  atmospheric  changes,  and  speed- 
ily get  beyond  control. 

The  ordinary  diarrhea  of  teething  consists  of  green  or  yellow 
matter  with  small  lumps  of  undigested  curd.  The  latter  char- 
acteristic is  obviously  due  to  a  fault  of  digestion,  and  if  attrib- 
uted solely  to  the  teeth  might  be  allowed  to  go  on  without 
treatment,  which  would  be  decidedly  improper.  Food,  such 
as  milk,  that  may  have  been  perfectly  well  digested  under  other 
circumstances,  may  be  entirely  indigestible  now,  and  if  so, 
should  be  changed  to  cream  or  raw-meat  juice  or  to  some  other 
bland  and  unirritating  food,  and  remedies  should  be  adminis- 
tered to  relieve  the  gastric  irritability  before  milk  can  safely  be 
resumed  again. 

Premature  Decay  of  Teeth. — There  is  a  marked  differ- 
ence in  children  as  regards  the  tendency  to  decay  in  the  decid- 
uous teeth.  As  a  rule,  more  or  less  of  them  decay  before  they 
fall  out,  and  before  the  permanent  set  are  ready  to  replace 
them.  In  such  cases  it  is  very  bad  practice  to  have  them 
extracted,  for  the  reason  that  the  pressure  of  the  tooth  in  its 
socket  is  necessary  to  preserve  the  contour  of  the  jaw-bone  and 
prevent  the  permanent  tooth  behind  it  from  coming  in  crooked. 

When  the  milk  teeth  are  extracted  prematurely,  the  perma- 
nent set  are  almost  certain  to  present  an  irregular  and  unsightly 
outline.  This  can  easily  be  prevented  by  killing  the  nerve  of 
the  milk  tooth  with  creosote  or  otherwise,  and  filling  the  cavity 
with  cement  or  some  inexpensive  miaterial  that  will  stop  the 
tooth  from  aching  and  preserve  its  usefulness,  until  its  fellow 
of  the  permanent  set  is  ready  to  take  its  place. 

As  soon  as  one  of  these  teeth  shows  signs  of  decay,  the  child 
should  be  taken  to  a  dental  surgeon  at  once.  If  delayed,  the 
tooth  will  soon  begin  to  ache  and  the  child  will  refuse  to  use 
it  for  purposes  of  mastication.  As  a  result  the  food  will  be 
"  bolted,"  indigestion  will  follow,  and  immense  mischief  may 
result. 

D.  C— 15 


226  THE  DISEASES  OF  CHILDREN. 

The  Permanent  Teeth. — The  second  or  permanent  set  of 
teeth  numbers  thirty-two,  and  erupt  in  the  following  order,  those 
of  the  lower  jaw  preceding  those  of  the  upper : 

Sixth  year,  first  molars. 
Seventh  year,  central  incisors. 
Eighth  year,  lateral  incisors. 
Tenth  year,  first  bicuspids. 
Eleventh  year,  second  bicuspids. 
Twelfth  to  thirteenth  year,  canines. 
Thirteenth  to  fifteenth  year,  second  molars. 
Seventeenth  to  twenty-first  year,  wisdom  teeth. 

It  will  be  noticed  that  the  permanent  teeth  are  as  many 
years  in  erupting  as  the  milk  teeth  are  months,  which  fact 
explains  in  a  measure,  at  least,  why  the  system  is  so  much 
more  liable  to  be  disordered  in  the  latter  case  than  in  the 
former. 

Treatment  of  Dentition. — In  the  majority  of  cases  the 
troubles  which  are  incidental  to  teething  are  not  attended  with 
danger,  but  are  trifling  in  their  nature  and  transient  in  their  ef- 
fects. Some  infants,  however,  suffer  torture  with  every  new 
tooth  and  require  relief  quite  as  much  as  if  the  disturbance  was 
more  serious.  Fortunately  for  these  sufferers,  there  are  many 
remedies  of  great  value,  which,  properly  given,  may  not  only 
ameliorate  present  pain,  but  obviate  serious  complications. 
When  simple  diarrhea  is  present,  it  does  not,  as  already  inti- 
mated, require  treatment  so  long  as  it  remains  simple  and  not 
profuse  enough  to  cause  exhaustion.  Should  it  pass  these 
bounds,  however,  such  remedies  as  are  mentioned  under  the 
head  of  Diarrhea  may  be  given,  the  particular  remedy  being 
chosen  with  regard  to  the  special  indications  of  the  case.  In 
case  the  stomach  is  irritable  from  reflex  sympathy,  it  may  be 
necessary  with  bottle-fed  infants,  to  change  the  food  tempo- 
rarily to  one  more  bland  and  easily  digested.  When  cow's 
milk  has  been  used,  cream  may  be  advantageously  substituted 
for  a  few  days,  or  some  one  of  the  more  easily  digested  baby 
foods,  although  it  be  less  nutritious  and  tissue-making  than 
that  previously  given.  After  a  day  or  two  the  regular  food 
should  be  resumed.  Barley  water  or  the  bread  jelly  mentioned 
on  page  56  may  answer  temporarily.  When  the  teeth  are  slow 
in  making  their  appearance,  or  when  they  decay  soon  after 
eruption,  calcarea  carb.  should  be  given  in  the  third  decimal 
trituration,  a  one-grain  powder  three  or  four  times  daily.  In 
case  the  teeth  are  much  delayed  and  the  gums  remain  a  long 
time  swollen,  white  and  painful,  calc.  phos.  is  the  remedy.     It 


TREA  TMENT  OF  DENTITION.  227 

is  all  the  more  indicated  if  the  infant  sweats  much  about  the 
head  whenever  it  falls  asleep. 

When  there  is  a  hacking  cough  (symptomatic  or  reflex),  nux 
vomica ;  this  remedy  is  also  indicated  in  constipation. 

With  violent  thirst,  heat,  fever  and  restlessness,  aconite. 

Belladonna  is  indicated  by  starting  in  sleep,  face  flushed, 
jerking  or  twitching  of  muscles,  as  if  convulsions  were  im- 
pending. 

When  there  is  sleeplessness,  much  agitation,  now  crying  and 
then  gay,  coffea.  If  convulsions  have  already  developed,  gel- 
semium  or  cuprum,  according  to  their  special  indications, 
should  be  given.     (See  passiflora.) 

The  symptoms  calling  for  ignatia  are  trembling  all  over  ; 
piercing  screams ;  convulsive  jerkings  of  single  parts  ;  stools 
attended  with  tenesmus  and  prolapse  of  the  anus;  child  cries 
and  sobs,  and  the  latter  continues  after  the  crying  subsides. 
Mercurius  Sol. — copious  salivation,  and  sometimes  little  blis- 
ters are  seen  on  the  tongue,  gums  and  cheeks  ;  quite  large  ulcers 
are  sometimes  seen  on  the  protruding  gum ;  sleeplessness ; 
stools  green,  slimy  and  accompanied  with  tenesmus.  Silicia — 
in  scrofulous  children  who  easily  take  cold,  stools  diflficult,  dry 
and  hard ;  the  stool  often  recedes  before  its  passage  is  effected  ; 
profuse  sour-smelling  perspiration  covering  entire  body,  or  af- 
fecting the  feet  more  particularly ;  fever  toward  evening,  and 
lasting  into  the  night.  Hellebens  nig. — when  brain  symptoms 
predominate,  and  a  hydrocephaloid  condition  exists  or  seems 
impending ;  child  has  spells  of  frenzy,  very  excitable ;  com- 
plains of  falling ;  sleeps  badly  ;  stools  white  and  jelly-like.  But 
the  remedy  of  all  remedies,  and  the  one  most  often  called  for 
during  the  teething  period,  is  chamomilla.  This  remedy  is  to 
infants  and  children  what  Pulsatilla  is  to  women ;  a  veritable 
vade  mecum.  Its  special  indications  are  great  restlessness,  start- 
ing and  jumping  in  sleep ;  when  awake  it  wants  to  be  carried 
all  the  time  ;  one  cheek  red,  the  other  pale  ;  great  thirst ;  gums 
red  and  tender  ;  dry,  hacking  cough  ;  very  thirsty,  likes  to  hold 
its  mouth  a  long  time  in  cold  water  while  drinking ;  stools 
grass-green,  or  slimy  with  mucus.  The  symptoms  are  very 
similar  to  coffea  and  belladonna,  but  it  has  a  different  colored 
stool,  and  the  symptoms  are  more  manifestly  of  local  origin. 

At  the  risk  of  seeming  to  be  dogmatic,  I  would  say  that 
aconite^  belladonna,  chamomilla  and  gelsemium  form  a  quartette 
of  remedies  that  will  meet  nearly  every  indication  arising  in 
the  course  of  teething,  where  remedies  are  called  for.  There  is 
another  remedy  with  which  I  have  recently  become  acquainted, 
and  which  seems  to  meet  the  erethism  present  in  these  cases 
better  than  any  other  remedy.     It  is  passiflora,  or  the  passion- 


228  THE  DISEASES  OF  CHILDREN. 

flower.  No  proving  has  yet  been  made  of  it,  that  we  are  aware 
of,  and  it  is  generally  used  in  the  form  of  the  tincture  or  fluid 
extract.  Of  the  tincture,  ten  to  fifteen  drops  may  be  given 
to  a  child  under  six  months  of  age,  and  to  an  older  child  twice 
this  quantity.  It  is  used  somewhat  empirically  by  the  eclectic 
school  for  convulsions,  nervousness,  wakefulness,  and  tetanoid 
conditions.  In  three  cases  of  eclampsia  in  which  I  have  used  it, 
it  gave  prompt  relief ;  diminished  the  severity  and  frequency 
•of  the  spasms,  and  seemed  to  act  promptly  and  continuously. 
In  one  case  where  an  infant  a  year  old  had  been  having  spasms 
at  frequent  intervals  for  twenty-four  hours,  only  one  convulsion 
occurred  after  this  remedy  was  given.  It  should  be  given  in  a 
little  sweetened  water.  In  all  cases  where  the  physician  is 
called  to  attend  a  young  infant  or  child,  the  state  of  the  gums 
should  be  ascertained  by  personal  inspection.  In  many  in- 
stances the  gums  will  be  found  swollen,  hot  and  tender,  and  the 
promptest  relief  will  be  afforded  by  incising  them. 

The  Gum  Lancet  in  Difficult  Dentition. — It  seems 
passing  strange  that  nearly  all  recent  authors  on  the  diseases  of 
children  speak  slightingly  or  deprecatingly  of  the  lancing  of 
gums  of  teething  children,  while  all  recent  authors  on  dental 
surgery  are  outspokenly  in  favor  of  it.  Such  eminent  authori- 
ties as  Rilliet  and  Barthez  utterly  discountenance  it,  while  one 
of  the  latest  and  highest  authorities  in  this  country  makes  the 
statement  that  the  gum  lancet  "is  used  more  by  the  ignorant 
practitioner  who  is  deficient  in  the  ability  to  diagnosticate  ob- 
scure diseases  than  by  an  intelligent  man  who  can  discover 
more  clearly  the  true  pathological  state."  Such  a  statement  as 
this,  coming  from  such  high  authority,  would  be  paralyzing  to 
the  young  practitioner  were  it  not  a  well-known  fact  that  many 
children  die  of  convulsions,  or  drift  into  a  hopeless  eclampsia, 
when  the  most  rigid  search  by  the  most  skillful  physician  can 
reveal  no  pathological  state  except  tender  and  swollen  gums 
overlying  an  impacted  tooth,  that  may  be  released  and  all  pain 
and  reflex  phenomena  relieved  immediately  by  the  use  of  the 
gum  lancet. 

A  case  recently  sent  to  me  for  diagnosis  and  advice  by  my 
friend.  Dr.  J.  D.  Burns,  of  Grundy  Center,  Iowa,  will  illustrate 
what  has  just  been  said.  The  child  was  a  girl  eighteen  months 
old,  well  developed  and  the  picture  of  rosy  health.  The  doctor 
may  tell  his  own  story.  I  quote  from  the  letter  which  accom- 
panied the  child.  "  For  nearly  a  year  she  has  been  troubled 
with  a  nervous  affection  which  does  not  yield  to  treatment. 
The  trouble  is  spasmodic  in  its  nature  and  epileptiform  in 
type.     The  peculiarity  is  that  she  always  cries  and  holds  her 


GUM  LANCET  IN  DIFFICULT  DENTITION.         229 

breath  at  the  beginning  or  onset,  the  spasm  being  preceded  by 
more  or  less  jerking  of  the  tendons,  when  a  general  spasm  en- 
sues, first  tonic,  then  clonic,  lasting  from  a  few  minutes  to  a 
half,  and  the  mother  says  a  whole,  hour,  which  is  succeeded  by 
great  exhaustion,  drowsiness  or  sleep.  The  spasms  recur  at 
indefinite  periods  of  a  day  or  two  or  a  week.  I  have  used  sev- 
eral remedies  with  no  apparent   benefit." 

I  learned  from  the  parents  who  brought  the  child  and  the  let- 
ter at  the  same  time  that  the  spasms,  as  they  undoubtedly  were, 
dated  back  some  months,  at  which  time  the  child  was  eight 
months  old  and  cutting  its  first  teeth.  Up  to  this  time  she  had 
been  perfectly  well,  a  good  feeder,  a  good  sleeper  and  regular 
in  all  her  functions.  When  brought  to  me  she  had  eight  teeth, 
but  all  of  them  had  come  through  the  gums  with  difficulty. 
Shortly  before  the  successive  appearance  of  each  tooth  the 
"  spells,"  as  the  mother  called  them,  were  more  frequent. 
Twice  it  happened — being  recalled'to  mind  during  the  examina- 
tion— that  they  occurred  at  the  dinner  table  while  the  child 
was  sucking  the  handle  of  a  teaspoon  or  table  knife.  It  was 
further  recalled  that  any  sudden  shutting  of  the  jaws  together, 
as  in  a  fall  on  the  floor,  was  followed  by  a  spasm.  An  inspec- 
tion of  the  mouth  showed  the  gums  over  the  first  molars  to  be 
hard,  tense  and  swollen.  On  using  the  gum  lancet  an  unusual 
amount  of  fibrous  tissue  was  encountered,  which  cut  like  gristle. 
A  crucial  incision  was  made  deep  down  to  the  crown  of  the 
tooth,  but  only  a  drop  or  two  of  blood  exuded  as  a  result ;  the 
child,  however,  immediately  began  to  cry  and  went  into  a  spasm 
which  lasted  about  five  minutes. 

Both  before  and  after  lancing  the  gums  I  made  a  most  ex- 
haustive physical  examination  of  the  child,  to  see  if  I  could  find 
any  "  pathological  state,"  other  than  teething,  to  account  for 
the  pathological  condition,  but  with  negative  results.  The 
case  was  evidently  one  of  eclampsia,  with  an  epileptiform  ten- 
dency. My  prognosis  was  a  guarded  one.  The  eclampsia  had 
been  of  so  long  standing — nearly  a  year — that  the  convulsive 
habit  had  become  established.  The  result  will  probably  be  death 
or  a  confirmed  epilepsy.  But  if  the  strictest  care  be  taken  to  re- 
lieve the  nervous  system  from  undue  irritation  by  frequent  and 
deep  scarifications  of  the  gums,  and  a  proper  attention  be  given 
to  diet  while  the  teething  process  is  going  on,  possibly  better 
results  may  be  obtained. 

Some  three  months  after  first  seeing  this  case  I  received  from 
Dr.  Burns  the  following  letter,  in  answer  to  my  inquiry  as  to 
how  the  case  was  progressing: 

Dear  Doctor — Yours  of  the  20th  inst.  inquiring  about  the  Wilson  child 
received  today.     In  answer  would  say,  the   child  is  somewhat  better;  the 


230  THE  DISEASES  OF  CHILDREN. 

spasms  are  less  frequent  and  less  severe,  but  she  still  has  spasms.  I  have 
cut  her  gums  five  or  six  times,  every  time  down  to  the  teeth,  but  they  erupt 
slowly,  and  the  gums  are  as  tough  as  cartilage,  and  grate  under  the  knife ; 
have  continued  the  passiflora  in  from  5  to  15  drops  every  two  to  six  hours. 
I  have  used  other  remedies,  viz.:  santonin  3X,  nux  vom.  3X,  ignatia  3X; 
changed  the  food,  dilated  rectum  and  urethra,  used  a  4-per-cent.  sol.  of  co- 
caine on  the  gums,  etc.  I  am  satisfied  the  great  source  of  irritation  is  the 
teeth  and  digestive  system.  I  have  never  seen  such  tough  gums,  and  tender, 
too.     Every  time  they  are  freely  lanced  she  is  better. 

If  this  were  an  isolated  case,  the  argument  in  favor  of  lancing 
the  gums  would  have  but  a  flimsy  foundation.  But  such  a 
case  as  is  here  described  is  not  isolated.  Every  physician  of 
extensive  practice  must  have  met  many  similar  ones.  I  recall 
many  cases  myself  of  extreme  restlessness,  fever,  diarrhea,  ina- 
bility to  nurse,  with  jumping  and  starting  in  sleep,  all  of  which 
symptoms  were  promptly  relieved,  without  medicines,  by  incis- 
ing the  swollen  gums. 

The  symptoms  just  referred  to  may  precede  the  eruption  of 
a  tooth  by  several  weeks — when,  as  old  nurses  say,  the  teeth 
are  "  breeding  "  in  the  gums.  It  should  be  understood  that  the 
object  of  cutting  the  gum  is  not  merely  to  hasten  the  cutting 
of  a  tooth.  There  is  generally  no  necessity  for  haste  in  this 
matter,  unless  there  be  obvious  constitutional  disturbance 
resulting  from  delay.  This  disturbance  and  any  reflex  phe- 
nomena secondary  to  it  do  not  arise  from  pressure  of  the  tooth 
upward  against  the  gum,  but  downward  against  the  dental 
nerve  at  the  tooth  root.  As  the  tooth  progresses  forward  the 
root  of  the  tooth  progresses  downward.  When  dentition 
advances  normally  the  alveolar  processes  of  the  jaw,  which 
have  hitherto  confined  the  tooth  closely,  are  absorbed  and 
cease  to  hinder  its  advancement  and  nothing  prevents  the  rapid 
and  painless  eruption  of  the  tooth,  but  the  covering  of  the  gum. 
When  this  covering  is  thick,  tense  and  inflamed,  the  eruption  of 
the  tooth  is  delayed  and  an  incision  of  the  gum  affords  imme- 
diate relief.  When  absorption  of  the  alveolar  processes  does 
not  take  place  synchronously  with  the  other  phases  of  tooth 
evolution ;  when,  in  other  words,  the  obstruction  is  in  the  jaw 
rather  than  in  its  coverings,  lancing  the  gum  is  obviously  of 
little  or  no  avail.  It  is  during  the  "  breeding"  stage,  or  later 
on,  when  the  advancement  of  the  tooth  is  hindered  by  the  un- 
due thickness  or  undue  hardness  of  the  soft  covering,  that  lanc- 
ing is  most  beneficial.  In  these  cases  we  find  the  gum  promi- 
nent and  in  a  state  of  tension  over  the  advancing  tooth.  Under 
these  conditions  the  gum  should  be  divided  down  to  the  surface 
of  the  tooth,  not  at  a  point  only,  but  across  the  whole  breadth 
or  length  of  the  crown  ;  in  fact,  the  imprisoned  organ  should 
be  set  free. 


GUM  LANCET  IN  DIFFICULT  DENTITION.         231 

The  objections  urged  against  lancing  the  gums  are  so  illog- 
ical or  so  trifling  as  to  be  scarcely  worthy  of  serious  consider- 
ation, and  to  need. only  a  few  words  of  refutation.  The  possi- 
bility of  serious  hemorrhage  is  very  remote ;  so  rarely  is  it 
encountered  that  I  have  never  seen  it,  but  even  if  it  were  more 
frequent  the  same  argument  would  apply  to  every  surgical 
operation  and  to  all  medication.  No  procedure  should  be 
abandoned  or  forbidden,  nor  is  it  contra-indicated,  because  of  an 
occasional  fatality,  the  result  of  an  idiosyncrasy  or  of  exceptional 
and  unexpected  complication.  As  a  rule  there  is  no  such  dan- 
ger, and  the  operation  is  safe  and  practically  painless.  That  the 
operation  sometimes  demands  frequent  repetition  is  no  more 
of  an  objection  than  appertains  to  any  medication  which  fails 
to  afTord  permanent  relief  from  a  single  dose.  There  is  posi- 
tively no  danger  of  injury  to  the  developing  tooth  or  its 
enamel,  except  through  the  grossest  ignorance  of  the  anatomy 
of  the  mouth  or  through  the  most  culpable  carelessness. 
Probably  the  most  commonly  urged  objection  is  that  unless  the 
tooth  is  erupted  before  there  is  time  for  the  wound  to  heal  a 
cicatricial  tissue  is  formed,  which  offers  increased  resistance. 
This  argument  is  in  direct  contravention  of  recognized  facts  as 
to  the  reparative  process.  Cicatricial  tissue  is  always  and 
everywhere  of  a  lower  degree  of  organization  than  the  original 
structure,  and  consequently  easier  of  absorption.  The  tendency 
of  scar  tissue  to  break  down  by  reason  of  its  lower  vitality  is  a 
matter  of  common  observation,  and,  except  in  the  case  of  gum- 
lancing,  is  not  disputed  by  any  medical  authority.  Gum  tissue 
offers  no  exception  to  the  general  rule. 

While  the  operation  of  lancing  the  gum  is  a  trifling  one,  the 
manner  in  which  it  is  performed  has  much  to  do  with  its  success 
or  failure.  As  has  been  already  stated,  the  object  is  not  merely 
or  chiefly  to  cause  a  flow  of  blood,  but  to  remove  tension.  The 
cuts  should,  therefore,  be  made  with  special  reference  to  the 
form  of  the  erupting  tooth,  and  should  be  suflficiently  deep  to 
reach  the  presenting  surface  and  to  extend  fully  up  to  and  a 
little  beyond  its  boundaries,  so  as  to  insure  its  entire  liberation. 
It  is  well  to  direct  the  point  of  the  lance  toward  the  lips, 
instead  of  toward  the  lingual  or  palatal  surface  of  the  oral  teeth, 
as  there  is  thus  less  liability  to  injure  the  crypts  of  the  perma- 
nent teeth,  if  from  any  cause  the  cuts  should  be  made  deeper 
than  intended.  Partial  eruption  of  a  tooth  is  generally  accepted 
as  a  solution  of  the  problem,  the  slightest  presentation  being 
considered  as  definitely  deciding  against  the  necessity  of  lanc- 
ing. This  is  generally  true  in  the  case  of  the  incisors — far  from 
true  of  the  cuspids  and  molars.  The  cone  shape  of  the  cuspids 
insures   a  persistence   of   the   trouble,  from    pressure   of  the 


232  THE  DISEASES  OF  CHILDREN. 

inclosing  ring  of  gum,  until  fully  erupted.  A  complete  severance 
of  this  fibrous  ring  on  the  anterior  and  posterior,  as  well  as 
lateral,  surface  is  indicated,  and  is  even  more  necessary  than 
before  the  partial  eruption  of  the  tooth.  All  the  cusps  of  a 
molar  may  have  erupted,  and  yet  strong  bands  of  fibrous  integu- 
ment maintain  a  resistance  as  decided  as  before  their  appear- 
ance. In  this  case  either  the  boundaries  of  the  tooth  should 
be  traced  with  the  lancet  and  all  such  bands  severed  around  its 
outlines,  or  a  crucial  incision  should  be  made  so  as  to  insure 
perfect  release  from  pressure. 

Whenever  lancing  of  the  gums  is  deemed  necessary,  it  should 
be  done  in  the  spirit  of  the  adage,  "  What  is  worth  doing  at  all 
is  worth  doing  well."  The  modus  operandi  in  carrying  out 
this  aphorism  is  so  well  described  by  Dr.  James  W.  White,  in 
the  "American  System  of  Dentistry,"  that  I  beg  leave,  for  the 
benefit  of  young  practitioners,  to  give  it   in  his  own  words : 

"  The  operator  should  be  seated  directly  in  front  of  his  assist- 
ant, the  knees  of  the  two  parties  corresponding  in  height. 
Some  direct  the  child  to  be  held  cross-wise  on  the  lap  of  the 
assistant ;  others  prefer  to  be  behind  the  head  of  the  child  to 
operate  on  the  left  side,  and  in  front  to  operate  on  the  right 
side  of  either  jaw.  Others  take  the  head  on  their  knees  when 
operating  on  the  upper  jaw,  and  place  the  head  on  the  knees 
of  the  assistant  when  operating  on  the  lower  jaw."  (In  either 
position  it  will  be  observed  that  the  assistant  has  complete  con- 
trol of  the  hands  of  the  child.)  "  The  left  hand  of  the  operator 
should  separate  the  jaws  and  protect  the  tongue  and  lips  of  the 
child  in  such  a  manner  that  any  unexpected  movement  may 
result  in  injury  to  his  own  fingers  rather  than  to  the  child.  In 
the  case  of  a  child  disposed  to  bite,  the  insertion  of  a  small 
cork  between  the  jaws  will  be  of  service.  This  should  be 
guarded  from  falling  into  the  throat  by  a  piece  of  string  or 
tape,  which  should  be  held  in  the  desired  position  by  the  as- 
sistant." It  is  rarely  necessary  to  use  this  expedient,  or  to  use 
any  force  after  a  child  has  once  submitted  to  the  operation,  for 
the  pain  is  so  trifling,  and  the  relief  from  suffering  so  great  and 
immediate,  that  it  is  desired  rather  than  feared. 

The  instrument  employed  should  always  be  a  gum  lancet^ 
used  for  this  purpose  and  for  no  other.  An  ordinary  bistoury 
used  for  miscellaneous  purposes  is  never  permissible. 

We  have  sometimes  derived  benefit  from  having  the  gums 
rubbed  occasionally  with  a  two  to  four  per  cent,  solution  of  co- 
caine ;  chamomilla  and  witch  hazel  are  also  palliative  when 
rubbed  on  the  gums,  and  may  be  used  when  lancing  the  gums 
is  contra-indicated  or  is  objected  to. 


PARX     IV. 

DIATHETIC     DISEASES. 


CHAPTER  I. 
GENERAL     CONSIDERATIONS. 

The  diseases  which  we  are  about  to  consider,  are  variously- 
designated  by  authors  as  the  diathetic,  cachectic  or  the  constitu- 
tional maladies.  They  are  very  widely  distributed  among  the 
human  family,  but  are  much  more  common  in  civilized  coun- 
tries than  in  those  which  are  semi-civilized,  or  barbarous.  They 
are  far  more  common,  also,  among  the  poor  and  squalid,  than 
among  the  wealthy  and  well-to-do.  With  the  possible  excep- 
tion of  tuberculosis,  they  are  not  contagious  nor  infectious. 
The  question  of  their  hereditary  origin  is  one  about  which 
authorities  differ,  and  about  which  volumes  might  be  written 
without  reaching  a  definite  conclusion.  Even  if  it  were  other- 
wise, the  question  could  have  no  practical  bearing,  and  we 
therefore  leave  it  to  those  who  have  a  special  taste  for  polemi- 
cal discussions.  Either  of  them  may  be  congenital,  but  more 
often  they  do  not  exhibit  their  symptoms  until  some  time  after 
birth.  They  all  incline  to  be  chronic  rather  than  acute  ;  and 
may  remain  in  a  latent  condition  for  a  lifetime  without  appar- 
ently abbreviating  life  itself.  They  are  all  characterized  by 
such  distinct  and  positive  symptoms  as  not  to  be  easily  mis- 
taken one  for  the  other. 

One  of  the  peculiarities  of  this  group  of  diseases  is  that  each 
and  all,  either  primarily  or  secondarily,  involve  the  nutritive 
sphere  of  activity,  and  work  their  principal  ravages  in  the  elab- 
orative  organs  of  the  body. 

In  tuberculosis  and  scrofula,  the  great  lymphatic  system  is 
principally  involved.  The  importance  of  this  system  has,  we 
think,  been  underestimated  by  physiologists  and  neglected  by 
pathologists.     Indeed,   the  whole  glandular  apparatus,  whose 

(233) 


234  THE  DISEASES  OF  CHILDREN. 

ramifications  are  co-extensive  with  vitality,  is  but  imperfectly 
understood.  The  real  functions  of  the  liver  and  spleen  are  to- 
day involved  in  doubt  and  speculation.  This  much  seems  prob- 
able, that  the  lymphatics  constitute  the  great  absorbent  system, 
whose  office  is  to  take  care  of  waste  products,  and  at  the  same 
time  furnish,  in  part,  at  least,  the  necessary  material  for  the  re- 
newal of  life.  It  is  the  connecting  link  between  the  alimentary 
canal  and  the  blood  current,  on  the  one  hand,  and  an  accessory 
venous  system  on  the  other.  In  early  life  the  lymphatic  system  is 
very  active,  much  more  so  than  in  maturity,  and  any  derangement 
along  the  course  of  its  innumerablechannels  is  sure  to  be  attended 
by  some  sort  of  mischief.  The  lymphatics  may  be  atrophied  con- 
genitally,  or  by  acquisition,  and  in  either  case  we  have  as  a  result, 
a  lack  of  growth  and  feeble  powers  of  vitality,  from  a  starved  con- 
dition of  nerve  centers.  On  the  other  hand,  and  in  contrast  with 
the  anemia  which  attends  atrophy,  we  may  have  an  hypertrophied 
condition  of  the  lymphatic  glands,  in  which  case  we  have  an 
excess  of  white  corpuscles  in  the  blood,  a  condition  known  as 
leucemia  or  leucocythemia. 

This  hypertrophy  of  lymphatic  glands  causes  the  develop- 
ment of  small,  painless,  compressible  tumors,  which  are  espe- 
cially noticeable  in  the  lumbar,  mesenteric,  epigastric  and  bron- 
chial structures. 

Microscopical  examination  in  hypertrophy  of  this  simple 
variety,  shows  only  the  normal  elements  of  glands,  and  the  to- 
tal absence  of  any  pathological  new  formation.  In  this  respect 
it  differs  materially  from  the  hypertrophy  accompanied  by 
inflammation,  which  we  find  in  scrofula,  and  there  is  no  tend- 
ency in  simple  hypertrophy  to  suppuration.  Its  prominent 
symptom  is,  in  addition  to  the  swellings  above  mentioned,  a 
sickly  pallor  of  countenance,  a  waxy  hue  of  the  skin,  and  a 
generally  debilitated  state  of  the  system.  The  causes  most 
active  in  the  production  of  this  condition  are  unsuitable  food 
and  bad  hygienic  surroundings — conditions  which  medicines 
are  powerless  to  overcome. 


CHAPTER  II. 

RACHITIS  (rickets). 

Definition  ;  Course. — Rachitis  is  essentially  a  disease  of  the 
bones  or  of  the  bone-producing  tissues,  and  is  a  common  re- 
sult of  faulty  diet  and  of  anti-hygienic  conditions.  It  is 
preeminently  a  disease  of  infancy,  having  but  little  in  common 
with  that  disease  of  mature  life  known  as  osteo-malacia. 

For  purposes  of  clinical  study  the  disease  may  be  divided 
into  three  stages :  first,  the  stage  of  invasion,  which  is  essentially 
one  of  malnutrition  ;  second,  a  stage  of  deformity,  during  which 
there  is  more  or  less  distortion  of  some  of  the  bones  of  the 
skeleton — the  most  noticeable  changes  being  usually  in  the 
bones  of  the  head,  the  ribs  and  the  radial  bones ;  the  third 
stage  is  one  of  reconstruction  or  repair,  during  which  the  de- 
formities resulting  from  the  disease  are  in  most  cases  so  nearly 
overcome  that  in  mature  life  but  little  if  any  trace  of  them  is 
left  except  in  stunted  growth,  which  neither  nature  nor  art  can 
rectify. 

Frequency. — The  world  over,  rickets  is  known  as  the  English 
disease ;  but  just  why  is  hard  to  explain,  for  statistics  do  not 
show  any  great  preponderance  of  it  in  the  British  Isles  over 
other  countries  where  the  population  is  equally  compact,  and 
where  the  communities  are  similarly  domiciled.  The  fact  is, 
the  disease  is  prevalent  in  all  countries  and  among  all  nations, 
and  if  the  health  records  were  equally  well  kept,  there  would 
probably  be  found  little  difference  in  prevalency  in  one  country 
over  another.  But  statistics,  however  reliable  they  rn^ay  be  in 
a  general  way,  are  utterly  valueless  in  estimating  the  relative 
prevalency  of  rachitis,  for  the  reason  that  its  inception  is  insidi- 
ous, and  its  progress  is  often  arrested  before  medical  treatment 
is  invoked.  Many  cases  of  rachitis  do  not  go  beyond  the  incip- 
ient stage,  when  fortuitous  circumstances,  such  as  change  of 
diet  or  air,  produce  a  spontaneous  arrest  of  the  disease,  and 
not  even  the  family  physician  is  made  aware  of  the  fact  that  a 
rachitic  condition  has  been  menacing. 

Such  cases  as  these  never  reach  the  record  books  of  hospital 
or   dispensary.      Furthermore,  the   symptoms  of  rachitis  are 

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236  THE  DISEASES  OF  CHILDREN. 

often  complicated  by  those  of  other  disorders,  of  an  acute  na- 
ture, such  as  bronchitis  and  affections  of  the  stomach  and  bow- 
els, which  overshadow  and  obscure  the  fundamental  trouble 
and  cause  it  to  be  overlooked.  In  a  somewhat  loose  and  un- 
scientific, but  still  in  a  practical  and  emphatic  way,  one  can 
judge  something  of  the  prevalence  of  pronounced  cases  of  the 
disease  by  noticing  the  number  of  undersized  and  bow-legged 
males,  and  of  females  with  illy-formed  shoulders  and  backs,  in 
any  community  in  which  he  may  happen  to  be,  for  the  major- 
ity of  these  distorted  forms  are  occasioned  by  early  rickets.  It 
is  quite  true  that  other  causes  besides  rickets  arrest  growth 
and  prevent  the  bodies  of  children  from  reaching  an  ideal  form  ; 
but  no  other  disease  is  so  commonly  responsible  for  malforma- 
tions and  a  lack  of  symmetrical  development.  Jenner  says  : 
"  Rickets  is  the  most  common,  the  most  important,  and  in  its 
effects  the  most  fatal  of  diseases  which  extensively  affect  chil- 
dren." Hassowitz  says  that  in  Vienna  the  number  of  cases 
among  all  classes,  rarely  falls  below  eighty  per  cent.  Dr. 
Thomas  Barlow  says,  "  If  the  question  of  craniotabes  be  left 
out,  and  attention  be  carefully  directed  to  the  junction-area 
of  the  fifth  and  sixth  ribs,  there  will  be  no  difficulty  in  finding 
at  least  fifty  per  cent,  of  examples  of  distinctive  rickets  among 
children  under  two  years  attending  the  out-patients'  depart- 
ments of  London  and  Manchester."  These  figures  are  mani- 
festly merely  estimates,  but  may  be  taken  for  what  they  are 
worth.  They  point  out  the  fact  very  plainly  that  rachitis  is 
very  much  more  frequently  met  with  than  has  been  generally 
supposed. 

Causes. — There  is  the  greatest  diversity  of  opinion  among 
pathologists  as  to  the  real  cause  of  rickets.  Vogel,  Parrot,  and 
many  others  believe  that  constitutional  syphilis  in  the  parent 
may  cause  rickets  in  the  children.  Others  of  equal  eminence 
deny  this  in  toto. 

However  we  may  regard  the  disease  from  a  controversial 
standpoint ;  how  many  soever  factors  may  be  considered  as 
entering  into  the  etiology  of  a  given  case,  all  authorities  are 
agreed  upon  one  point,  viz.,  that  the  one  factor  that  enters 
prominently  into  every  case  is  the  factor  of  defective  food.  It 
matters  not  whether  the  rachitic  child  has  been  nursed  at  the 
breast  or  has  been  bottle-fed,  the  one  indictment  that  cannot 
be  quashed,  the  one  fact  that  cannot  be  denied,  is  the  insuffi- 
ciency or  inefficiency  of  the  food  supply.  In  the  beginning  of 
every  case  of  rickets,  there  is  somewhere  a  fault  that  amounts 
to  a  failure,  in  the  matter  of  alimentation.  The  nourishment 
does  not  nourish.  Some  essential  element  necessary  to  the 
economy  is  either  absent  or  is  presented  in  a  form  which  is 


RACHITIS.  237 

ineffective.  With  a  ravenous  appetite  there  is  lack  of  normal 
growth.  With  abundance  of  aHment  there  is  perverted  nutri- 
tion. Abundance  does  not  satisfy  ;  there  is  starvation  in  the 
midst  of  plenty. 

When  breast-fed  children  develop  the  rachitic  habit,  it  is 
usually  not  until  after  they  are  eight  or  ten  months  old,  at 
which  time  it  is  well  known  the  milk  of  nursing  women  is  apt 
to  deteriorate.  This  fact  is  a  very  significant  one.  All  statis- 
tics relating  to  the  subject  go  to  show  that  there  is  a  direct 
and  proportionate  relationship  between  prolonged  lactation 
and  rachitis.  Women  who  nurse  their  children  into  the  second 
year,  either  because  breast-milk  is  cheaper  than  other  food,  or 
because  of  a  fancied  immunity  from  pregnancy  which  nursing 
is  supposed  to  afford,  or  for  other  reasons,  should  know  that 
their  children  are  very  apt  to  be  rachitic.  Then  again,  there 
are  women  whose  milk  is  never  good,  no  matter  how  abundant 
it  is,  nor  how  young  and  seemingly  healthy  are  the  women  them- 
selves. A  woman  who  has  once  nursed  a  rachitic  child  should 
never  attempt  to  nurse  another  one.  But  with  all  nursing 
women  there  comes  a  time  when  the  milk  loses  its  nutritive 
qualities  and  becomes  as  an  aliment  but  little  better  than 
water.  When  such  is  the  case,  if  nursing  is  persisted  in,  the 
infant  is  in  great  danger  of  developing  rickets.  I  know  of  no 
reliable  means  of  ascertaining  the  time  when,  in  a  given  case, 
the  milk  begins  to  deteriorate  by  any  chemical,  mechanical  or 
microscopical  test.  The  time  unquestionably  varies  with  dif- 
ferent women,  and  with  the  same  woman  at  different  times  ; 
but  I  am  satisfied  from  personal  observations,  that,  with  Amer- 
ican women,  especially  with  those  living  in  large  cities,  this 
time  is  on  the  average  less  than  twelve  months.  Indeed,  in 
some  cases  it  may  be  as  early  as  the  fifth  or  sixth  month.  The 
occurrence  of  pregnancy  or  the  return  of  menstruation  hastens 
it.  To  nurse  a  child  beyond  this  time,  whether  it  occurs  sooner 
or  later,  is  always  perilous.  But  the  nursling  is  not  the  one 
most  commonly  menaced  by  rachitis.  As  we  have  endeavored 
to  show  in  the  chapter  on  Foods  and  Feeding,  the  bottle-fed 
infant  is  the  one  who  is  most  heavily  handicapped  in  the  race 
of  life  ;  and  it  is  the  artificially  fed  children  who  most  readily 
fall  victims  to  this  disease.  But  it  ought  not  to  be  so.  The 
principles  of  bottle  feeding  are  reasonably  clear,  and  the  variety 
of  wholesome  foods  is  ample  for  ordinary  needs,  if  only 
intelligently  selected.  Many  children  drift  into  a  rachitic 
state  very  soon  after  being  weaned,  because  of  a  mistaken 
idea  that  a  healthy  infant  can  go  directly  from  the  nurse's 
breast  to  the  general  table  and  there  be  fed  on  whatever  its 
fancy  dictates. 


238  THE  DISEASES  OF  CHILDREN. 

Histological. — Malnutrition  is  the  principal  characteristic  of 
the  initial  stage  of  rickets.  Until  quite  recently  it  was  held 
that  certain  deleterious  elements,  admitted  into  the  system  with 
the  food,  or  generated  within  the  system  from  the  food,  stood 
in  their  relation  to  rickets  as  cause  and  effect.  Experiments 
made  on  the  lower  animals,  especially  on  dogs  and  rabbits,  show 
that  rickets  can  be  produced  in  them  at  pleasure,  by  giving 
them  lactic  acid  in  small  but  frequently  repeated  doses  while 
they  are  yet  young.  It  was  thought,  therefore,  that  the  gen- 
eration of  lactic  acid  within  the  system  from  the  use  of  starchy 
foods  was  the  prime  factor  in  the  causation  of  rickets.  This 
acid,  it  is  well  known,  is  commonly  produced  in  large  quantities 
in  young  children  as  a  result  of  improper  feeding,  and  thus  a 
satisfactory  solution  of  this  vexed  question  seemed  easily 
reached.  But  the  clinical  fact  has  been  elicited  that  children 
develop  a  rachitic  condition,  in  whose  blood  there  is  certainly 
no  excess  of  lactic  acid.  On  this  point,  Dr.  J.  Lewis  Smith 
says:  "Rachitis  sometimes  occurs  in  infants  who  present  no 
history  of  indigestion  or  of  intestinal  catarrh,  and  in  whom  there 
is  no  ground  for  the  belief  that  lactic  acid,  or  any  other  acid,  is 
produced  in  undue  or  injurious  quantity.  In  a  considerable 
proportion  of  such  cases,  inquiry  elicits  the  fact  of  anti-hygienic 
conditions,  but  there  is  no  evidence  of  imperfect  digestion  or 
of  gastro-intestinal  catarrh,  such  as  produces  lactic  acid.  In 
the  cases  occurring  in  the  New  York  Infant  Asylum,  alluded  to 
above,  some  of  the  children  had  manifest  gastro-intestinal  de- 
rangement, but  others,  who  were  wet-nursed,  gave  no  evidence 
of  faulty  digestion,  though  the  nutriment  which  they  received, 
was  probably  insufificient ;  for,  as  already  stated,  by  providing  a 
more  liberal  diet,  by  allowing,  among  other  articles,  the  juice  of 
meat,  rachitis  became  much  less  frequent  and  is  seldom  observed 
at  present  among  the  infants  of  that  institution,  unless  in  a  very 
mild  form." 

The  experiments  of  Heitzmann,  Virchow  and  others  show 
that  one  of  the  factors  in  the  production  of  rachitis,  is  a  defi- 
ciency of  calcareous  salts  in  the  food  supply ;  but  it  is  doubtful 
whether  an  excess  of  lactic  acid  or  the  deficiency  of  earthy  salts 
is  sufficient  alone  to  produce  the  disease,  or  whether  both  con- 
ditions combined  are  present  in  all  cases. 

On  the  contrary,  there  is  good  reason  to  believe  that  the 
causes  are  not  uniform  in  all  cases,  but  that  varying  conditions 
operate  in  different  patients  to  produce  the  same  pathological 
result. 

This  pathological  result  is  a  disproportion  between  the  organic 
matter  and  the  earthy  salts  in  the  various  bones  which  make 
up  the  framework  of  the  organism.    In  healthy  bones  the  inor- 


RACHITIS.  23f> 

ganic  elements  predominate  over  the  organic  in  the  proportion 
of  two  to  one  ;  but  in  rickets  the  proportion  is  reversed,  the 
organic  matter  being  greatly  in  excess.  There  is  a  great  diver- 
sity of  opinion  as  to  just  how  the  disproportion  of  elements 
originates.  Some  maintain  that  the  earthy  salts  are  not  elab- 
orated into  bone,  the  process  of  ossification  being  arrested  in 
its  course  ;  while  others  claim  that,  by  reason  of  the  excess  of 
lactic  acid  present,  the  bony  matter  is  absorbed  or  dissolved 
after  being  wholly  or  partially  elaborated,  leaving  the  organic 
matter  but  little  altered. 

If  a  long  bone  be  macerated  in  acid  for  a  time  sufficiently 
long  to  dissolve  out  the  inorganic  matter,  it  becomes  possible 
to  bend  and  twist  it  at  pleasure.  Such  a  bone  is  typical  of  one 
affected  by  the  rachitic  disease.  About  the  ends  of  the  long 
bones  we  find  a  proliferation  of  the  cartilage  cells,  and  in  conse- 
quence a  growth  of  bone  which  is  larger  and  coarser  than  the 
same  in  health.  A  rachitic  bone  when  dried  is  so  openly  porous 
that  one  can  readily  breathe  through  it  as  through  a  sponge. 
In  a  rachitic  bone  the  ends  of  the  shafts  are  ossified  by  cells 
not  only  larger,  but  more  fragile  than  normal,  while  along  the 
center  of  these  long  bones  ossification  is  so  slow  and  imperfect 
that  it  readily  bends  when  subjected  to  any  weight  or  pressure. 
In  mild  cases  of  rickets  only  a  few  bones  may  be  affected  ;  but  in 
severe  cases  every  bone  in  the  skeleton  may  be  more  or  less 
altered  in  its  histological  elements.  The  tendency  of  the  disease 
is  always  to  shorten  the  long  bones,  such  as  those  of  the  limbs, 
and  to  soften  the  flat  bones,  such  as  those  of  the  skull.  This 
accounts  for  the  square  box  shape  of  the  head,  and  the  stunt- 
ing of  the  figure  of  a  rachitic  child.  The  retarded  ossification 
of  the  bones  in  rachitis  is  more  marked  in  some  bones  than  in 
others.  It  is  especially  noticeable  in  those  of  the  skull.  The 
sutures  remain  open  for  a  long  time  and  the  fontanels  do  not 
close  until  long  after  they  should.  In  a  healthy  infant  the 
anterior  fontanel  should  be  closed  between  the  fifteenth  and 
twentieth  months,  but  in  the  rachitic  it  may  remain  open  for 
two  or  three  years. 

In  should  be  borne  in  mind  that  in  the  normal  state  of  affairs 
the  brain  increases  in  size  during  the  first  six  or  seven  months, 
more  rapidly  than  does  the  development  of  bone,  so  that  up  to 
this  age  the  anterior  fontanel  is  larger  than  at  birth  ;  but  after 
the  ninth  month  it  becomes  progressively  smaller,  until  it  is 
finally  closed  at  the  age  above  mentioned. 

The  other  bones  which  exhibit  most  strikingly  the  rachitic 
change,  are  the  ribs  and  the  radius — the  sternal  end  of  the  ribs 
and  the  lower  end  of  the  radius. 

It  is  seldom  that  these  bones  do  not  give  evidence  of  the 


240  THE  DISEASES  OF  CHILDREN. 

disease,  if  it  be  present,  and  in  greater  degree  than  other  bones. 
They  are  the  first  to  be  affected  to  an  extent  that  is  appre- 
ciable to  the  observer. 

Craniotabes,  first  described  by  Elsasser  in  1843,  has  till  lately 
always  been  held  to  be  a  sign  of  rickets.  M.  Parrot  and  others 
have  called  this  doctrine  in  question,  and  considerthe  complaint 
a  sign,  not  of  rickets,  but  of  congenital  syphilis.  Craniotabes, 
or  wasting  of  the  skull,  is  a  condition  of  softening  of  the  bones, 
particularly  of  the  postero-parietal  region,  by  which,  under  mod- 
erate pressure  from  the  finger,  the  bone  caves  inward  with  a 
crackle  like  that  of  stiff  parchment.  It  is  of  two  kinds  :  in  very 
young  infants  the  bones  of  the  skull  will  yield  under  pressure, 
and  sometimes  crackle,  but  this  is  not  a  diseased  condition. 
The  true  disease  generally  exists  in  localized  patches.  It  is 
said  to  occur  in  thirty  to  forty  per  cent,  of  all  cases  of  rickets, 
and  is  found  to  perfection  from  six  months  after  birth  onwards. 
It  is  an  open  question  how  far  this  condition  is  due  to  uncom- 
plicated rickets,  and  how  far  to  syphilis ;  but  it  is  a  remarkable 
fact  that,  since  the  question  was  mooted,  some  very  weighty 
evidence  has  been  produced  in  favor  of  its  association  more 
with  syphilis  than  with  rickets.  Dr.  Thomas  Barlow  and  Dr. 
Lees  collected  100  cases  of  craniotabes,  and  have  published 
the  results  of  a  most  careful  inquiry  upon  its  relationship  both 
to  syphilis  and  rickets.  From  it  they  conclude  that  forty-seven 
per  cent,  of  the  total  are  almost  certainly  syphilitic ;  and  t'o 
this  may  be  added  the  observation  of  Dr.  Baxter,  that  of  the 
twenty-three  per  cent,  of  craniotabes  in  rachitic  children, 
seventy-five  per  cent,  were  syphilitic. 

The  skull  of  a  child  affected  with  craniotabes  shows  shallow 
depressions  at  the  diseased  parts,  smoothly  bevelled  off  into  the 
surrounding  bone.  The  depressed  areas  may  be  so  numerous 
as  to  give  the  inner  table  a  somewhat  trabeculated  appearance. 
The  thin  layer  of  bone  which  covers  in  the  depression  is  that 
which  gives  the  crackle  as  it  bends  inwards  on  pressure.  In 
some  cases  the  thinning  is  more  general,  involving,  perhaps,  the 
entire  occipital  bone  ;  in  others,  the  local  thinning  is  consider- 
able, and  may  go  on  to  the  formation  of  a  number  of  mem- 
branous opercula.  In  other  cases,  again — and  the  real  nature  of 
such  is  still  open  to  question — there  is  much  tendency,  not  only 
to  thinning  and  softening,  but  to  the  formation  of  new  bone, 
in  most  cases  leading  to  the  production  of  a  velvet  pile-like 
layer  of  osteophyte  over  the  surface  of  the  calvaria  between  the 
sutures  and  the  centers  of  ossification.  In  this  way  the  sutures 
come  to  form  furrows,  and  the  shape  of  a  hot  cross-bun  is  pro- 
duced— the  natiform  skull — and  sometimes  the  bone  formation 
may  be  so  active  that  the  skull  may  reach  a  thickness  of  half 


RACHITIS.  241 

an  inch  or  more.  The  new  bone  is  very  soft  in  all  these  cases, 
can  be  cut  with  a  knife,  and  is  of  a  peculiar  claret  color,  from 
the  amount  of  blood  it  contains.  Many  consider  this  condition 
of  the  skull  to  be  a  sign  of  congenital  syphilis.  It  is  certainly 
frequently  found  in  syphilitic  infants — in  infants  in  whom  other 
evidences  of  rickets,  though  not  absent,  are  yet  of  the  slightest. 
Nevertheless,  I  do  not  think  that  one  can  altogether  exclude 
rickets  from  a  share  in  its  production. 

Other  signs  of  rickets  are  found  in  the  epiphyseal  extremities 
of  the  long  bones,  and  in  the  ribs.  In  these  the  ossifying  layer 
of  cartilage  at  the  junction  of  the  epiphysis  with  the  shaft,  or 
in  the  case  of  the  ribs  at  the  junction  of  the  costal  cartilage 
with  the  bone,  becomes  swollen — sometimes  enormously  so — 
and  thus  is  produced  a  characteristic  swelling  of  wrists  and 
ankles,  and  a  beading  of  the  ribs.  These  symptoms,  although 
present  in  most  cases,  are  by  no  means  remarkable  in  many.  A 
child  may  be  very  rachitic  as  regards  its  head  and  dentition, 
and  perhaps  show  a  distorted  thorax,  enlargement  of  the  spleen, 
and  even  curvature  of  its  bones,  while  yet  there  is  but  little 
enlargement  either  of  the  ends  of  the  ribs  or  of  radius  or  tibia. 

The  bones  are  soft  in  rickets,  and  thus  come  sundry  charac- 
teristic distortions  of  spine,  thorax,  pelvis,  and  long  bones.  In 
the  thorax  a  double  curve  is  assumed,  the  ribs  fall  in  at  their 
junction  with  the  costal  cartilages,  and  a  vertical  depression  of 
considerable  extent  is  produced  in  such  parts  of  the  thorax  as 
are  not  supported  by  the  solid  viscera.  The  abdominal  viscera 
prevent  the  falling  in  of  the  lower  part  of  the  chest ;  the  lat- 
eral parts  of  the  upper  segment  fall  in  considerably ;  whilst  the 
sternum  becomes  rounded  and  prominent,  and  the  antero-pos- 
terior  diameter  of  the  chest  becomes  the  dominant  one.  Some 
have  distinguished  between  this,  the  chest  of  the  rickety  child, 
and  the  distortion  due  to  other  causes,  such  as  atelectasis,  or 
non-expansion  of  the  lung.  In  the  latter  the  ribs  yield  gener- 
ally from  their  angles  forwards,  and  the  transverse  section  of  the 
chest  becomes  of  a  peg-top  or  angular  shape,  from  the  sternum 
becoming  carinated.  On  a  priori  grounds  it  may  be  argued 
that  the  softened  bone  curves,  not  only  at  the  epiphyses,  but 
also  generally  in  its  length ;  there  is  ample  evidence  that  it 
actually  does  so ;  and  there  seems  little  reason  why  the  ribs 
should  not  thus  yield.  The  worse  the  rachitic  condition,  so 
much  the  more  yielding  will  there  be,  and  the  lateral  grooves 
will  then  be  pronounced.  In  the  less  severe  cases  the  recession 
of  the  chest-wall  will  be  less,  and  che  chest  will  approach  the 
angular  type.  Moreover,  by  no  means  is  it  certain  that  this 
shape  does  not  represent  a  partial  obliteration  of  the  more 
marked  distortions.  It  is  much  more  common  in  children  of 
D.  C— 16 


242  THE  DISEASES  OF  CHILDREN. 

six,  eight,  or  ten  years.  The  grooved  chest  is  the  common 
type  of  infancy.  It  is  certain  that,  as  the  child  grows  and  the 
bones  harden,  the  deeper  dip  of  the  ribs  at  the  costo-chondral 
articulations  gradually  expands  again ;  while  the  antero-pos- 
terior  expansion  of  the  lung  has  become  in  a  measure  perma- 
nent, and  tends  to  perpetuate  the  prominence  of  the  sternum. 
In  the  same  manner  occur  those  distortions  of  the  pelvis,  which 
are  so  commonly  noticed  in  the  victims  of  rickets. 

That  of  mollities  ossium  is  beaked,  or  Y-shaped  ;  of  rickets^ 
contracted  in  its  antero-posterior  capacity  by  the  sacral  prom- 
ontory being  unduly  prominent.  But  in  extreme  cases  of 
rickets,  when  the  body  weight  has  been  unduly  thrown  upon 
the  pelvis,  the  acetabula  may  be  forced  backwards  into  the 
pelvis,  and  a  beak  be  produced  by  the  symphysis  and  pubic 
bones.  The  fibula  and  tibia  bow  outwards  and  forwards ; 
the  radius  and  ulna  curve  outwards ;  and  in  extreme  cases  the 
natural  curves  of  the  clavicles  become  much  exaggerated. 
These  conditions  go  with  (sometimes  they  may  be  replaced  by) 
an  unnatural  relaxation  of  the  ligaments,  particularly  at  the 
knees,  and  thus  cause  the  knock-knees  and  bandy-legs  that  are 
so  often  seen  in  late  cases  of  rickets. 

A  good  deal  of  discussion  has  been  carried  on  as  regards  the 
cause  of  all  these  deformities.  Some  have  contended  for  mus- 
cular force  acting  on  soft  bones  ;  others  for  simple  weight — the 
bones,  not  being  strong  enough,  yielding  under  the  weight  they 
are  called  to  support.  Both  these  forces  are  probably  entitled 
to  some  consideration  ;  but  the  theory  which  attributes  the 
curvatures  to  undue  weight  is  no  doubt  the  more  important, 
and  most  of  them  may  be  understood  and  explained  by  a  con- 
sideration of  the  direction  in  which  the  force  has  acted.  In 
one  case  it  may  be  the  weight  of  the  body  in  walking ;  in  an- 
other, that  of  one  part  of  the  limb  upon  the  remainder,  in  cer- 
tain recumbent  postures.  In  the  arms  it  is  due  to  those  parts 
being  used  as  a  help  to  progression,  the  child  moving  on  all- 
fours.  In  the  thorax  some  have  attributed  the  distortion  to  a 
combination  of  softening  of  the  bones  with  collapse  of  the  lungs, 
which  is  a  frequent  associate  and  consequence  of  rickets ;  'oth- 
ers to  softening  of  the  bone,  and  a  yielding  under  the  inspira- 
tory pull  of  the  muscles.  Of  this,  however,  there  can  be  no 
doubt,  that  the  disease  in  the  thorax  is  almost  constantly  asso- 
ciated with  bronchitis  and  atelectasis,  and  that  in  the  bones  of 
the  spine  and  extremities  curvatures  never  reach  any  extreme 
form  in  such  as  have  not  been  allowed  to  walk  or  sit  up  unduly. 

Another  important  point  as  regards  the  rachitic  skeleton  is 
that  the  bones  are  stunted  in  their  growth,  and  in  extreme 
cases  the  child  may  be  severely  dwarfed  by  this  means. 


RACHITIS.  243 

._  Symptoms. — Rachitis  is  a  non-febrile  disease.  The  inflamma- 
tion which  some  pathologists  maintain  must  accompany  the 
bone  changes  which  occur  as  a  part  of  the  malady  is  sub-acute, 
and  does  not  become  general  enough  to  raise  the  body  temper- 
ature except  in  rare  and  exceptional  cases.  Ordinarily  the 
disease  is  insidious  and  slow  in  its  development,  occupying 
months  in  its  gradual  and  progressive  course,  before  even  those 
changes  occur  in  the  skeleton  which  are  so  characteristic. 

The  essential  symptoms  of  the  initial  stage  of  rachitis  are 
those  of  indigestion  and  intestinal  catarrh,  such  as  flatulence, 
unhealthy  stools,  poor  and  capricious  appetite  and  all  the 
accompaniments  of  malnutrition. 

The  evidences  of  indigestion  and  malassimilation  are  accom- 
panied by  marked  mental  characteristics.  The  child  is  cross, 
peevish  and  irritable.  Its  sleep  is  easily  disturbed  and  it 
awakens  often.  Its  appetite  may  be  unimpaired  or  capricious, 
sometimes  it  is  ravenous.  But  it  does  not  grow.  It  does  not 
care  to  play  like  a  healthy  child.  On  the  contrary,  it  repels  all 
attempts  to  amuse  it  as  if  annoyed  by  them.  It  resents  being 
handled  or  fondled  and  cries  when  approached,  as  if  it  feared  to 
be  touched.  It  prefers  to  be  let  alone  and  will  lie  for  hours  in  a 
state  of  listless  melancholy,  rather  than  suffer  the  pain  which 
comes  from  being  disturbed.  This  soreness  is  partly  muscular 
and  partly  due  to  the  changes  which  are  going  on  in  the  per- 
iosteum of  the  bones. 

Another  and  noticeable  symptom  of  incipient  rickets,  and 
frequently  the  first  one  to  attract  attention,  is  sweating  about 
the  head.  It  perspires  freely,  both  about  the  head  and  neck, 
especially  about  the  former. 

This  may  occur  when  the  child  is  awake  and  is  independent 
of  the  temperature  of  the  room  or  the  abundance  of  clothing. 
It  is,  however,  most  marked  when  the  child  is  asleep.  Its  pil- 
low is  v/et  with  perspiration  and  drops  of  sweat  may  be  seen  on 
the  forehead  and  face.  Cranial  perspiration  occurring  habit- 
ually whenever  the  child  sleeps  is  a  very  significant  sign.  It 
may  not  always  point  to  rickets,  but  is  always  a  dyscrasia. 

The  abdomen  early  becomes  distended  by  gases,  and  this, 
with  enlargement  of  liver  and  spleen,  produces  the  "  frog  belly  " 
so  frequently  seen  when  the  disease  is  well  marked.  The  veins 
of  the  temple  and  forehead  are  unduly  prominent  and  some- 
times those  also  of  the  neck  and  thorax.  The  child  is  prone  to 
kick  off  the  bed-clothes  at  night  as  if  the  weight  of  the  clothes 
was  intolerable. 

But  the  most  significant  and  certain  of  the  early  signs  of 
impending  rickets  is  found  in  the  delayed  evolution  of  the 
teeth.     I  do  not  refer  altogether  to  the  eruption  of  the  teeth 


244  THE  DISEASES  OF  CHILDREN. 

through  the  gums,  although  this  has  its  significance,  but  to  the 
whole  phenomenon  of  teething.  A  perfectly  healthy  child  should 
show  some  of  the  usual  signs  which  accompany  this  process  by 
the  fifth  or  sixth  month.  If  this  age  be  reached  and  there  be 
no  increase  of  the  salivary  secretion  ;  no  tumefaction  of  the 
gums ;  no  irritation  of  the  nervous  system  accompanied  with 
suggestive  actions  pointing  to  the  mouth  as  its  seat ;  if,  in  a 
word,  there  is  no  change  in  the  inner  contour  of  the  jaw  indica- 
tive of  activity  there ;  and  if  this  condition  goes  on  to  the 
seventh  or  eighth  month,  the  watchful  physician  should  be  on 
his  guard.  If,  in  addition,  cranial  perspiration  is  present  when- 
ever the  child  slumbers,  and  further,  if  the  mental  condition — 
the  settled,  characteristic  melancholy — is  apparent,  we  need  not 
wait  for  further  development  to  diagnose  the  disease. 

Another  symptom  connected  with  teething  is  often  present 
in  children  in  whom  the  disease  has  started  after  one  or  more 
teeth  have  erupted.  It  is  the  prolonged  interval  that  elapses 
between  the  cutting  of  single  teeth  or  pairs  of  them.  These 
intervals  are  reasonably  regular,  as  a  rule,  in  healthy  children, 
and  any  unusual  delay  in  the  continuance  of  the  process  of 
tooth  evolution,  after  it  has  once  begun,  should  not  be  allowed 
to  pass  unnoticed. 

These  symptoms  belong  to  the  first  stage  and  precede  that 
of  noticeable  deformity.  When  this  latter  stage  is  reached,  the 
most  evident  signs  are  to  be  observed  in  the  head,  ribs  and 
radius.  The  head  loses  its  vaulted  form  and  becomes  box-like. 
It  is  flattened  both  on  top  and  sides.  Its  antero-posterior  diam- 
eter is  elongated.  Its  width  is  also  increased.  The  size  of 
the  cranium  is  therefore  large,  but  not  usually  so  large  as  in 
hydrocephalus  or  hypertrophy  of  the  brain.  The  sutures  remain 
open,  so  that,  between  the  illy-developed  cranium  and  the 
equally  ill-nourished  brain,  there  is  often  fluid,  simply  filling 
up  the  space,  and  not  the  result  of  any  inflammatory 
effusion.  This  condition  is  termed  "  spurious  hydrocephalusy 
It  frequently  happens  in  rachitis  that  the  cranium  is  unsym- 
metrical. 

I  have  noticed  this  particularly  in  the  case  of  a  child  whose 
mother  had  the  use  of  but  one  breast.  This  compelled  the 
child  to  always  lie  on  the  same  side  while  nursing  and  the  pres- 
sure of  the  head  against  the  breast  had  markedly  flattened  that 
side  of  it. 

But  the  most  pathognomonic  symptoms  of  rickets  is  caused 
by  the  enlargement  of  the  epiphyseal  ends  of  the  ribs  where 
they  join  the  costal  cartilage.  This  is,  in  most  cases,  very  no- 
ticeable, and  constitutes  what  is  variously  called  the  "  row  of 
beads,"  the  "  rachitic  rosary,"  or  the  "  rachitic  garland."     The 


RACHITIS.  245 

wrists  also  enlarge,  owing  to  the  effect  of  the  disease  on  the 
epiphysis  of  the  radius. 

Complications. — The  rickety  condition  is  always  associated 
with  general  debility,  and  is  often  complicated  with  bronchitis, 
pneumonia,  whooping  cough,  the  eruptive  fevers,  tubercular 
disease  of  the  thorax  or  abdomen,  laryngismus  and  hydroceph- 
alus. Any  of  these  disorders  have  an  unfavorable  effect  on  the 
progress  of  the  malady,  for  whatever  reduces  the  general 
strength  and  weakens  the  constitution,  is  certain  to  retard  re- 
covery when  it  has  once  commenced.  The  changes  which 
take  place  in  the  thoracic  walls  have  an  injurious  effect  on  both 
the  heart  and  the  lungs.  The  heart  is  pressed  upon,  and  after 
a  time  more  or  less  hypertrophy  is  the  result.  In  a  case  which 
the  author  has  had  under  observation  for  some  two  years  past, 
in  a  child  now  nearly  three  years  old,  there  is  considerable  bulg- 
ing in  the  precordial  region  ;  and  the  pulsations  of  the  heart  have 
never  been  below  sixty  since  he  was  first  seen,  which  was  when 
he  was  about  ten  months  of  age.  His  respirations  now  average 
twenty.  This  child  has  passed  through  two  serious  attacks  of 
bronchitis,  during  which  his  respirations  were  as  high  as  eighty 
for  several  days,  but  he  ultimately  made  a  good  recovery.  The 
case  is  interesting  as  illustrating  several  points  in  the  foregoing 
pages  relative  to  the  course  and  causation  of  this  disease.  The 
father  and  mother  of  the  child  are  exceptionally  robust  and 
healthy.  The  father  is  over  six  feet  tall,  while  "the  mother  is 
but  four  inches  shorter.  Both  are  young,  and  this  was  their  first 
child.  A  few  weeks  after  he  was  born  the  mother  was  taken 
ill,  and  unable  to  continue  nursing  him.  He  was  placed  on  the 
bottle  and  various  baby  foods  given,  but  none  of  them  satisfied 
his  needs.  He  stopped  growing,  became  fretful  and  peevish, 
cried  whenever  anyone  looked  at  him,  sweat  a  great  deal  about 
the  head,  and  when  I  was  first  called  to  see  him,  he  was,  as 
stated  above,  ten  months  of  age  and  weighed  thirteen  pounds. 
It  was  three  months  after  the  writer  took  charge  of  him  before 
he  gained  a  pound  in  weight.  It  seemed  impossible  to  move 
him  away  from  this  fatal  number.  After  a  time,  however,  he 
slowly  began  to  gain,  until  now  at  the  age  of  four  and  one-half 
years  he  weighs  twenty-eight  pounds. 

A  year  ago,  I  delivered  this  mother  of  another  son,  and 
fortunately  she  was  able  to  nurse  it.  This  second  child  of 
these  parents  has  never  seen  a  sick  day  since  birth,  and  is  larger 
than  his  brother,  who  is  older  by  something  over  two  years. 

It  would  be  unfair  to  conclude  that,  because  one  of  these 
children  was  raised  on  the  bottle  and  the  other  at  the  breast, 
that  the  bottle  feeding  was  the  sole  cause  of  the  rickets.  I 
am  not  aware  what  food  was  first  used   in  the  case  nor  what 


246  THE  DISEASES  OF  CHILDREN. 

judgment  was  exercised  in  its  preparation,  but  in  my  opinion 
it  was  the  food  in  the  bottle  and  not  the  bottle  itself  that  was 
to  blame. 

The  lungs  are  apt  to  suffer  more  than  the  heart  in  cases  of 
rachitis  in  which  the  chest  is  distorted.  Semi-collapse  of  cer- 
tain lobules  is  apt  to  occur,  and  even  complete  collapse  of  the 
thin  edges  of  the  lung  is  not  uncommon.  In  such  cases  bron- 
chitis and  pneumonia  are  very  apt  to  prove  fatal. 

Laryngismus  stridulus  is  another  very  common  and  serious 
complication  in  rickets.  Laryngismus  is  sometimes  called 
"  child  crowing,"  from  the  peculiar  noise  which  is  made  at  each 
inspiration.  The  affection  consists  in  a  spasmodic  closure  or 
narrowing  of  the  glottis,  which  greatly  impedes  respiration  and 
while  it  lasts  it  seriously  threatens  life.  As  a  rule,  however, 
the  attack  lasts  but  a  few  seconds  and  is  harmless.  When  the 
attack  is  severe  and  prolonged,  there  is  a  fixation  of  the  dia- 
phragm, and  of  the  respiratory  muscles,  and  the  thumbs  and 
fingers  become  tightly  flexed  on  the  palms.  A  slight  degree 
of  cyanosis  may  occur  and  general  convulsions  may  supervene. 

Prognosis. — So  far  as  the  disease  itself  is  concerned,  the  prog- 
nosis in  rachitis  is  good.  Death  rarely  results  from  its  direct 
eflects.  Owing  to  the  depressed  and  narrowed  condition  of  the 
thorax,  the  action  of  the  heart  and  lungs  is  embarrassed,  and 
any  disease  of  the  respiratory  functions  is  consequently  more 
serious  in  a  child  affected  with  rickets.  Under  these  circum- 
stances, bronchitis  and  pneumonia  are  attended  by  increased 
dangers.  Whooping  cough  also  is  much  more  serious  when  it 
complicates  rachitis.  If  the  cough  be  severe  while  the  ribs  are 
soft  and  yielding,  and  there  be  lateral  depression  of  the  thorax, 
the  spasmodic  cough  produces  great  suffering  and  involves  dan- 
ger. Measles,  when  attended  by  considerable  bronchitis  or 
broncho-pneumonia,  is  another  of  the  dangerous  inter-current 
diseases.  Among  the  remote  results  of  rachitis,  which  compli- 
cate the  prognosis,  and  render  it  somewhat  doubtful  so  far  as 
longevity  is  concerned,  is  the  danger  to  married  females,  from 
the  deformity  and  stunted  growth  of  the  pelvic  bones,  should 
they  become  pregnant.  Labor  is  often  seriously  complicated 
by  distortion  of  the  pelvis  in  women,  who  have  been  rachitic  in 
infancy.  The  older  the  child  is  when  rachitis  begins,  the  milder 
is  its  ordinary  course,  and  the  less  is  the  resultant  deformity. 

Treatment. — That  rachitis  should  be  as  prevalent  among  all 
classes  of  society,  as  is  indicated,  in  the  early  part  of  the  chap- 
ter, is  an  opprobrium  medicorum,  for  if  any  disease  is  prevent- 
able it  is  this  one.  No  well-fed  child  has  rickets.  It  cannot 
be  too  emphatically  impressed  upon  the  medical  student  that 
whenever  a  child  shows  signs  of  rickets,  an  avoidable  error  in 


RACHITIS.  247 

its  diet  has  been  made  ;  and  the  first  step  in  the  way  of  treat- 
ment is  to  correct  this  error.  It  is  neither  an  act  of  prudence 
or  wisdom  to  delay  a  radical  change  in  food.  If  the  child  has 
been  nursed  at  the  breast  and  under  five  or  six  months  of  age, 
the  nurse  should  be  changed ;  but  if  older  than  this,  it  should 
be  placed  on  artificial  food  and  part  of  its  diet,  no  matter  what 
particular  cereal  is  used,  should  be  of  an  animal  nature.  If 
cow's  milk  is  tolerated,  well  and  good;  but  if  not,  the  juice  of 
raw  meat  should  be  given — the  meat  juice  being  prepared  as 
directed  on  page  6i. 

When  the  child  gives  evidence  that  it  is  not  thriving  on  the 
particular  food  which  has  been  selected  for  it,  another  must  be 
chosen,  regardless  of  preconceived  opinions  or  notions. 

We  have  had  the  best  success  in  rachitis  with  the  Liebig 
food,  in  which  the  starch  it  contains  has  been  converted  into 
glucose.  It  so  happens  that  we  have  always  used  the  prepara- 
tion of  malted  food  known  as  Mellin's,  and  after  twenty  years* 
experience  with  it  we  can  say  that  we  have  never  known  an 
infant  to  become  rachitic  under  its  use,  while  we  have  known 
many  to  recover  who  had  become  rachitic  under  other  foods. 

Cow's  milk  as  an  exclusive  diet  is  in  these  cases  inadmissible. 
Its  tendency  to  form  lactic  acid  simply  feeds  the  morbid  pro- 
cess. All  foods  requiring  the  addition  of  cane  sugar,  to  make 
them  palatable,  are  injurious  for  the  same  reason.  If  an  atom 
of  cane  sugar  be  split  in  two,  the  result  is  an  atom  of  lactic 
acid  and  an  atom  of  alcohol. 

But  lactic  acid  is  already  in  excess  in  the  blood,  as  we  have 
seen,  and  is  busy  creating  mischief  in  all  the  tissues.  To  add 
more  is  to  add  fuel  to  the  flame.  All  forms  of  starchy  foods 
and  those  requiring  artificial  sweetening  are  pernicious,  and 
this  is  why  the  great  majority  of  the  so-called  "  baby  foods  "  fail 
to  meet  the  requirements  of  these  cases. 

This  subject  is  treated  of  so  fully,  however,  in  a  preceding 
chapter  that  nothing  further  need  be  said  here.  Fresh  air  and 
sunshine  are  very  necessary  to  the  subjects  of  rachitis.  Indeed, 
every  hygienic  measure  available  should  be  utilized,  for  there  is 
really  more  practical  value  to  be  derived  from  them  than  from 
drugs.  The  latter  are  valueless  without  the  former.  While 
the  bones  are  soft  and  yielding,  great  care  should  be  exercised 
to  prevent  deformities.  The  patient  should  not  be  encouraged 
to  use  the  limbs  or  bear  weight  upon  them  until  they  have 
become  firmer.  He  should  lie  on  an  even  and  soft  mattress, 
but  one  that  is  not  heating  to  the  body  like  feathers.  Bathing 
the  body  occasionally  with  dilute  hamamelis  or  alcohol  is 
helpful. 

Inunctions  of  olive  oil  following  the  bath,  are  of  service  also. 


248  THE  DISEASES  OF  CHILDREN. 

In  craniotabes,  the  pillow  should  be  of  hair — soft  and  yet  cool, 
and  care  must  be  taken  that  the  yielding  parts  of  the  cranium  are 
not  unduly  pressed  upon.  When  curvatures  are  unavoidable,  or- 
thopedic treatment  will  be  necessary,  but  should  not  be  resorted 
to  until  nature  has  had  an  opportunity  to  act  alone,  for  in  many 
cases,  as  the  muscles  strengthen,  the  bones  will  be  brought  into 
line.  Cumbersome  apparatuses  that  are  heavy  to  carry  are  apt 
to  do  more  harm  than  good. 

Medical  Treatment. — Any  one  who  has  read  the  pathogen- 
esis of  phosphorus  could  scarcely  fail  to  observe  the  striking 
similarity  between  the  symptoms  of  this  drug,  as  observed  in 
cases  of  phosphorus  poisoning,  and  rachitis.  It  has  produced 
osteomalacia  in  adults — a  disease  which  in  its  course  and  nature 
is  almost  identical  with  the  rickets  of  infancy.  It  has  produced 
rickets  in  young  dogs  and  rabbits,  when  given  to  them  experi- 
mentally. It  is  logical,  therefore,  to  expect  that  phosphorus 
would  prove  curative  in  this  disease,  and  such  is  the  case  as 
demonstrated  by  all  who  have  ever  employed  it.  While  there 
are  other  and  valuable  remedies  to  meet  the  various  peculiari- 
ties and  complications  which  are  liable  to  arise  in  the  course 
of  the  disease,  there  is  no  other  single  remedy  that  so  fully 
covers  the  typical  case,  from  its  inception  to  its  cure,  as  this 
one. 

But  we  do  not  get  its  best  value  when  it  is  given  in  its  simple 
and  direct  form.  It  combines  too  readily  with  oxygen  to  form 
phosphoric  acid,  to  perform  its  highest  functions.  Its  stability 
and  effectiveness  are  greatly  increased  by  adding  it  to  lime,  and 
forming  the  drug  we  know  as  calcarea  phosphorica,  and  in 
this  preparation  we  have  a  remedy  for  rachitis  which  is  par 
excellence. 

Its  sphere  of  action  covers  the  following  symptoms,  which 
are  those  of  a  typical  case  of  the  disease  we  are  now  consider- 
ing, to  wit :  Both  fontanels  open  ;  tardy  dentition  ;  sweating 
about  the  head;  abdomen  "pot-bellied  ;"  indisposition  to  be- 
ing handled  ;  soft,  spongy  condition  of  bone  ;  bones  fragile,  or 
easily  bent ;  settled  melancholy,  and,  indeed,  the  whole  cata- 
logue of  symptoms  which  are  so  characteristic  of  these  typical 
cases. 

Many  of  these  symptoms  are  also  covered  by  calcarea  car- 
bonica,  but  not  to  the  same  extent  and  fullness.  The  latter  is 
more  useful  in  the  incipient  stage  ;  the  former  after  the  disease 
has  become  fully  established.  Calc.  carb.  meets  more  directly 
the  objective  symptoms,  while  calcarea  phos.  more  the  subjec- 
tive ones.  The  first  acts  more  on  the  blood  and  the  soft  tissues, 
the  other  the  osseous,  and  the  harder  tissues.  The  one  acts 
superficially,  the  other  more  profoundly.     Whichever  remedy 


RACHITIS.  249 

is  used,  it  must  be  given  systematically  and  persistently  for  a 
long  time. 

Silicia. — Here,  as  elsewhere  in  bone  affections,  this  remedy  is 
of  the  greatest  value ;  there  are  few  cases  of  rickets  which  do 
not  call  for  silicia  at  some  stage  of  the  treatment.  I  have  ob- 
served, however,  that  when  it  is  given  for  some  time,  and  this 
regardless  of  the  potency,  there  will  appear  a  distressing,  gnaw- 
ing pain  in  the  stomach,  which  is  relieved  by  eating.  I  have 
hitherto  failed  in  relieving  this  by  a  simple  discontinuance  of 
the  remedy.  Nux  vomica  has  oftener  removed  it  than  any  other 
remedy,  but  not  always.  The  appearance  of  this  symptom 
must  be  the  signal  to  abandon  the  remedy  entirely.  Its  dura- 
tion is  uncertain,  but  rarely  exceeds  a  fortnight.  The  symp- 
toms calling  for  silicia  are  similar  to  those  of  calcarea  carbonica, 
with  the  following  exceptions :  the  body  is  much  emaciated, 
but  not  soft  and  flabby  ;  it  is  "  scrawny,"  skin  somewhat  indu- 
rated, with  tendency  to  boils. — Gilchrist. 

Other  remedies  that  may  be  consulted  are  mercurius  sol., 
colchicum,  assafetida,  and  sulphur. 

For  the  complications  which  are  so  common,  such  as  bron- 
chitis, pneumonia,  etc.,  the  indicated  remedies  should  be  given 
intercurrently  with  the  constitutional  remedy,  for  the  rachitic 
condition,  as  indicated  above.  When  laryngismus  stridulus 
supervenes,  it  requires  no  different  treatment  than  when  the 
same  thing  occurs  under  other  circumstances.  See  chapter  on 
this  subject. 


CHAPTER  III. 

ACUTE     TUBERCULOSIS. 

Definition. — This  is  a  disease  which  consists  of  a  deposition 
of  gray  granular  matter,  or  miliary  nodules,  into  the  various 
organs  and  tissues  scattered  throughout  the  body.  It  should 
not  be  confounded  with  pulmonary  phthisis,  for  the  reason 
that  while  this  condition  may  result  in  ulceration  or  destruction 
of  the  lung,  it  by  no  means  follows  that  it  always  does  so.  On 
the  contrary,  while  having  many  points  in  common,  the  two 
diseases  are  quite  distinct  and  tuberculosis  may  invade  nearly 
every  other  portion  of  the  body,  without  affecting  the  lungs 
at  all. 

It  is  a  general  disease  affecting  principally  infants  and  chil- 
dren, and  in  most  cases,  although  not  all,  is  to  be  attributed  to 
hereditary  predisposition. 

"  Phthisis "  is  a  term  used  to  indicate  a  tuberculous  condi- 
tion of  the  pulmonary  tissues,  those  tissues  being  principally  or 
primarily  affected ;  while  tuberculosis  is  employed  to  signify  a 
general  distribution  or  dissemination  of  tuberculous  matter 
throughout  the  system,  but  affecting  for  the  most  part  the  lym- 
phatic glands. 

The  word  "  tubercle  "  is  a  very  vague  one,  and  is  used  so 
differently  by  different  authors,  that  it  has  almost  ceased  to 
convey  any  definite  meaning,  or  indicate  with  certainty  any 
special  pathological  process. 

The  disease  here  referred  to  under  the  title  of  acute  tuber- 
culosis, is  one  which  commonly  presents  the  features  of  an  acute 
specific  fever  of  indefinite  type  and  without  any  special  signs 
pointing  to  local  mischief.  Yet  local  mischief  is  going  on 
apace ;  histological  elements  in  various  tissues  are  undergoing 
pathological  changes ;  lymphatic  glands  are  being  gorged  with 
"giant  cells,"  and  through  the  medium  of  the  lymph  channels 
the  tissues  generally  are  being  filled  with  poorly  organized  and 
very  vulnerable  spherical  cells  which,  on  slight  provocation, 
undergo  caseous  metamorphosis. 

The  gray  granulation  is  composed  of  caseous  matter,  which 
at  first  is  firm  and  translucent,  but  in  children  it  soon  loses  its 
translucence  and  turns  yellow. 
(250) 


ACUTE     TUBERCULOSIS.  '  251 

The  nodules  of  gray  or  yellow  granulations  are  of  various 
sizes,  from  a  pin's  head  to  a  millet  seed,  and  are  the  result  of 
a  specific  irritation  of  the  endothelia  of  the  lymphatics.  Rind- 
fleisch  describes  the  granule  as  a  product  of  inflammation,  and 
states  that  it  consists  in  an  increasing  accumulation  of  leuco- 
cytes in  the  connective  tissue  of  the  parts  irritated.  As  the 
lymphatics  are  everywhere,  in  all  the  membranes,  blood  vessels, 
nerve  tissues  and  bones,  as  well  as  in  the  glands,  so  we  may 
have  anywhere  or  everywhere  the  presence  of  gray  granular 
matter,  ready  at  any  time  to  cause  irritation,  inflammation  and 
to  finally,  circumstances  favoring,  degenerate  into  suppuration. 
The  presence  of  the  gray  granulation  in  any  tissue  is  quickly 
followed  by  inflammation  in  the  neighborhood  of  the  growths. 
In  the  case  of  a  serous  membrane,  such  as  the  meninges  of  the 
brain  or  the  peritoneum,  lymph  is  quickly  thrown  out,  and  in 
time  this  exudation  becomes  caseous.  When  this  occurs  in 
the  tissue  of  the  lungs,  bronchitis  or  catarrhal  pneumonia  is  set 
up,  and  in  case  of  a  fatal  \.^xm\n2X\ovi,  post-mortem  examination 
shows  degeneration  of  the  nodules  in  every  stage  of  progression. 
Ulceration  and  the  consequent  formation  of  tuberculous  cavi- 
ties  in  the  lungs  are  not  common  in  early  life,  although  they  do 
occur  in  exceptional  cases. 

In  the  intestines,  the  gray  and  yellow  granulations  occur, 
especially  in  the  smaller  bowel,  and  involve  principally  the 
ileum  and  the  part  of  the  caecum  in  the  neighborhood  of  the 
valve.  The  liver,  the  spleen  and  the  kidneys  are  frequently  the 
seat  of  these  tuberculous  deposits,  the  spleen  being  especially 
liable  to  attack. 

Causation. — Aside  from  heredity,  it  is  useless  at  the  present 
time  to  discuss  the  causes  which  lie  at  the  foundation  of  acute 
tuberculosis.  The  present  age  will  be  known  to  the  future  his- 
torian of  medical  progress  as  the  age  of  microbes.  Every 
disease  that  human  flesh  is  heir  to  is  now  popularly  supposed  to 
be  due  to  some  specific  microbe,  and  in  the  opinion  of  the  germ 
theorists  acute  tuberculosis  is  peculiarly  and  especially  due  to 
bacilli. 

To  broach  any  other  theory  would  be  to  go  counter  to  this 
popular  opinion,  and  would  lay  the  author  open  to  the  pre- 
sumption of  ignorance  or  to  inexcusable  skepticism.  Never- 
theless, there  are  those  high  in  authority  who  have  not  as  yet 
accepted  in  full  faith  the  idea  that  the  living  body  is  always, 
when  sick,  a  prey  to  inferior  and  infinitesimal  organisms. 

There  would  be  an  obligation  to  discuss  the  germ  theory  and 
prove  or  disprove  its  tenets,  if  its  advocates  based  any  modifi- 
cation of  treatment  upon  it  or  helped  to  answer  the  question, 
*'  Provided  it  is  true,  what  can  we  do  about  it?" 


252  THE  DISEASES  OF  CHILDREN. 

There  is,  however,  no  answer  to  the  query,  and  so  we  may 
as  well  admit  that  we  do  not  know  any  more  to-day  about  the 
actual  causes  of  this  disease  than  did  our  predecessors  of  a 
thousand  years  ago.  Humiliating  as  it  is  to  make  so  bold  a 
confession,  it  is  better  to  realize  and  face  the  truth,  than  to 
waste  valuable  time  in  the  futile  following  of  a  chimera. 

Symptoms. — Children  affected  with  tuberculosis,although  often 
of  delicate  appearance,  are  not  necessarily  thin  and  feeble  looking. 
In  many  cases  the  nutrition  is  good,  and  the  child  is  considered 
in  every  way  a  healthy  subject,  prior  to  the  development  of 
the  disease.  Sooner  or  later,  however,  symptoms  are  noticeable 
pointing  to  disease  of  special  organs.  These  symptoms  may 
point  to  the  brain  or  to  the  lungs,  in  which  case  we  have  such 
phenomena  as  is  described  under  the  head  of  tubercular  men- 
ingitis or  pulmonary  phthisis.  When  the  disease  is  general  or 
not  specially  localized,  we  have  only  vague,  indefinite  and 
insidious  signs  to  guide  us  in  our  diagnosis. 

General  malaise,  pallor,  wasting,  fatigue,  want  of  appetite, 
slight  fever,  etc.,  etc.,  may  mean  much  or  little,  and  only  close 
watchfulness  and  great  acumen  can  construe  them  properly. 
Time,  often,  is  the  only  aid  to  elucidate  the  truth.  Sometimes 
a  conclusion  is  scarcely  reached  before  intolerance  of  light, 
drowsiness,  squint,  are  noticed ;  quickly  followed  by  convul- 
sions, coma  and  death. 

Diagnosis. — As  already  indicated,  the  diagnosis  of  acute  tuber- 
culosis is  sometimes  very  perplexing.  At  best  the  symptoms  are 
vague  and  indefinite ;  the  fever  is  rarely  high,  and  in  the  early 
stages  may  be  wanting  altogether ;  the  gastro-intestinal  symp- 
toms are  usually  well  marked,  but  no  more  so  than  when  occur- 
ring independently  from  tubercle. 

The  disease  with  which  it  is  most  liable  to  be  confounded  is 
typhoid  fever.  This  is  especially  the  case  when  the  tubercular 
affection  begins  abruptly  with  high  fever,  headache  and  nose- 
bleed. But  typhoid  fever  has  a  more  regular  gradation  of  tem- 
perature, and  runs  a  more  even  and  regular  course  generally. 

Besides  this,  tuberculosis  is  prolonged  beyond  the  time  when 
we  ordinarily  look  for  a  fall  in  the  temperature  in  typhoid  cases. 
There  is  a  peculiar  distress  in  the  face  of  a  tuberculous  patient, 
that  is  wanting  in  the  other,  and  the  child  is  dull  and  spiritless. 
The  history  of  the  case  for  sometime  prior  to  the  present  attack 
is  somewhat  helpful. 

In  tuberculosis  there  is  usually  a  history'  of  several  attacks  of 
diarrhea,  which  cannot  be  accounted  for  by  errors  in  diet,  and 
a  gradual  emaciation  attended  by  mild  pyrexia.  In  an  infant 
there  is  frequently  more  or  less  edema  of  the  legs. 


TABES    MESENTERICA.  253 

If  typhoid  fever  be  excluded,  and  there  is  a  history  of  grad- 
ual wasting,  moderate  pyrexia  and  edema  of  the  lower  ex- 
tremities, and  more  especially  if  the  family  history  is  not  above 
suspicion,  the  diagnosis  of  tuberculosis  is  fairly  warranted. 

Prognosis. — This  is  not  usually  encouraging.  If  the  diagnosis 
of  acute  tuberculosis  is  clearly  established,  the  chances  of  recov- 
ery are  desperate.  The  early  symptoms  of  the  disease,  as  we 
have  seen,  are  rarely  sufificiently  plain  to  indicate  the  real  na- 
ture of  the  trouble,  until  the  general  system  is  filled  with  gran- 
ular deposits,  and  nutrition  is  irreparably  impaired. 

Treatment. — When  one  member  of  a  family  has  shown  evi- 
dences of  being  tuberculous,  the  other  members  should  be 
watched  with  the  greatest  solicitude,  and  if  possible,  placed 
under  better  hygienic  influences  and  healthier  environments,  in 
the  hope  of  anticipating  and  preventing  the  disease  in  them. 
The  country  is  preferable  to  the  city ;  and  a  dry  and  warm 
climate  better  than  a  damp  and  changeable  one.  As  soon  as 
the  first  symptoms  show  themselves  indicative  of  indigestion, 
catarrh  or  diarrhea,  they  should  receive  the  appropriate  reme- 
dies for  these  complaints.  The  diet  should  be  made  to  exclude 
an  excess  of  sweets  and  all  fermentable  matters.  In  a  fully 
declared  case  of  the  disease,  our  remedies  should  be  given,  not 
alone  in  the  hope  of  arresting  the  formation  of  tubercles,  but 
also  to  put  a  stop  to  enfeebling  complications.  The  remedies 
which  have  received  most  commendation  in  the  treatment  of 
acute  tuberculosis  are  iodium,  sulphur,  kali  iod.,  baptisia,  lyco- 
podium,  mercurius  and  calc.  phos. 

For  further  elucidation  of  this  subject,  the  reader  is  referred 
to  the  chapter  on  Pulmonary  Phthisis. 

TABES  MESENTERICA. 

Definition. — By  this  term  is  indicated  a  tuberculous  condition 
of  the  mesenteric  glands.  It  is  not  to  be  understood  that  the 
tubercles  in  this  disease  are  limited  to  these  glands;  for  tabes 
mesenterica  is  rarely,  if  ever,  a  simple  affection. 

Indeed,  when  tuberculous  nodules  are  sufficiently  large  or 
sufficiently  numerous  to  be  recognized  in  this  locality,  they  are 
usually  scattered,  at  the  same  time,  generally  throughout  the 
system,  and  a  case  of  acute,  general  tuberculosis  would  be 
phenomenal,  which  did  not,  at  the  same  time,  involve  the  mes- 
entery. 

It  is,  however,  only  in  a  small  proportion  of  cases  of  tubercu- 
losis that  the  mesenteric  glands  become  sufficiently  indurated 


254  THE  DISEASES  OF  CHILDREN. 

and  swollen  to  attract  attention  or  complicate  the  course  of 
the  general  disease. 

Symptoms. — The  most  prominent  features  of  tabes  mesen- 
terica  are  general  emaciation  and  a  tumid  abdomen. 

The  emaciation  is  sometimes  startling.  "  The  sub-cutaneous 
fat  disappears  rapidly.  The  skin  is  thin,  flabby  and  inelastic  ; 
round  the  limbs,  it  is  loose  and  hangs  like  a  bag  ;  when  taken  up 
between  the  fingers,  it  retains  the  fold  raised  in  the  lifting.  In 
the  beginning,  the  muscles  can  be  recognized ;  afterwards  even 
they  emaciate  to  such  an  extent  that  their  outlines  disappear, 
and  those  of  the  bones  are  distinctly  perceptible.  The  eyes  lie 
deep  in  the  orbits  and  have  a  peculiarly  dry  and  hungry  look. 
The  bones  of  the  face,  with  the  thin,  flaccid,  dry  and  scaly  skin 
over  them,  take  on  a  terribly  senile  expression.  The  surface  is 
mostly  cool,  the  limbs  are  cold,  the  cutaneous  veins  very  dis- 
tinct and  blue,  much  dilated  over  the  chest  and  still  more  so 
over  the  abdomen.  The  voice  is  thin  and  tin-like,  the  cry 
mostly  tearless,  the  pulse  slow  (from  the  heart-muscle),  or  more 
frequently  rapid,  thin  and  compressible.  The  lymph  bodies  of 
the  neck  and  the  inguinal  region,  sometimes  also  the  axilla,  are 
tumefied."  This  picture  of  tabes  mesenterica  is  more  or  less 
true  to  all  cases.  But  the  disease  is  not  without  variations.  In 
some  cases  the  appetite  is  wanting  and  in  others  it  is  voracious. 
Some  have  diarrhea  and  others  do  not.  In  all  cases  the  stools 
are  fetid.  In  the  majority  of  cases,  there  is  severe  intestinal 
catarrh,  attended  with  offensive  discharges.  The  peculiar  foul 
odor  is  largely  due  to  acids  formed  by  the  fat,  which  has  not 
been  absorbed,  sulphides,  and  other  products  of  putrefaction. 
The  stools  are  mostly  large  and  expelled  with  an  instantaneous 
gush.  Fever  is  not  always  present,  and  in  some  cases  the  tem- 
perature may  be  subnormal.  The  tumid  abdomen  is  sometimes 
sensitive  to  touch,  while  in  others  it  is  painless.  In  exceptional 
cases,  the  abdominal  walls  are  not  particularly  distended  and 
they  may  even  be  retracted ;  but  in  a  typical  case,  the  belly  is 
swollen  in  fearful  contrast  with  the  atrophied  state  of  the  mus- 
cles of  the  thorax  and  the  limbs.  When  tubercular  peritonitis 
supervenes,  as  it  sometimes  does,  the  abdominal  pain  on  pres- 
sure is  exquisite. 

When  the  abdomen  is  tympanitic,  the  superficial  veins  are 
dilated  and  prominent.  By  elevating  the  legs  and  relaxing  the 
abdominal  walls,  tuberculous  nodules  can  be  felt,  sometimes 
superficially  and  again  deep  down,  along  the  vertebral  column. 
The  tumefied  glands  attain  a  size  varying  from  that  of  an  almond 
to  a  pigeon's  egg,  or  larger,  and  occasionally  from  the  aggre- 
gation of  several  enlarged  glands,  a  mass  is  formed  double  the 
size  of  the  child's  fist.     In   many  cases  the  glands,  however 


TABES    MESENTERICA.  -  255 

large,  are  difficult  of  detection,  for  the  reason  that  they  are 
covered  and  concealed  by  coils  of  intestine.  When  the  abdo- 
men is  supple  and  relaxed,  however,  and  the  enlarged  glands 
are  in  the  neighborhood  of  the  umbilicus,  careful  palpation 
will  generally  discover  them.  The  variableness  of  the  distinc- 
tive symptoms  in  different  cases  would  render  the  diagnosis 
very  difficult,  if  only  those  of  a  local  character  had  to  be 
depended  upon.  The  history  of  the  case  and  the  concomitant 
symptoms  must  all  be  given  due  heed,  and  even  then,  there 
may  be  trouble  in  reaching  an  early  conclusion.  If  the  bowels 
are  constipated  the  intestines  are  apt  to  be  filled  with  gas,  and 
this  should  be  remedied  before  any  attempt  is  made  to  palpate 
the  abdomen.  In  advanced  cases,  the  cheesy  glands  infect  the 
the  peritoneum  in  their  neighborhood,  and  adhesions  occur 
between  the  intestinal  coils,  and  between  them  and  the  abdom- 
inal wall.  Irregular  distension  of  the  abdomen  is  thereby 
occasioned  and  much  intestinal  gurgling  and  rumbling.  Ulcer- 
ation of  a  tuberculous  mesenteric  gland  occasionally  occurs, 
with  perforation  of  the  intestine. 

Prognosis. — When  the  tuberculous  infiltration  is  largely  or 
wholly  limited  to  the  glands  of  the  mesentery,  the  prognosis  is 
by  no  means  hopeless,  but  the  more  the  general  system  is 
infected,  the  more  serious  and  desperate  the  case  becomes. 
Still  no  case  should  be  abandoned  as  hopeless,  however  dis- 
couraging it  may  appear,  for  it  is  never  possible  to  determine 
except  by  an  autopsy,  how  much  or  how  little  tuberculous  infil- 
tration exists,  and  the  severity  of  the  symptoms  are  not  a  safe 
criterion  upon  which  to  base  a  judgment. 

Duration. — These  cases  may  be  acute  or  chronic,  and  on  this 
fact  depends  the  length  or  brevity  of  the  attack.  Acute  cases 
may  last  for  several  weeks,  or  even  months,  after  the  symptoms 
have  become  sufficiently  pronounced  to  permit  of  a  diagnosis. 
Chronic  cases  may  last  for  months  or  even  years. 

Treatment. —  Infants  and  children  of  the  strumous  habit 
should  receive  especial  care  whenever  they  show  the  first  symp- 
toms of  diarrhea.  Any  irritation  of  the  intestinal  tract  is  liable 
to  affect  the  neighboring  glands,  and  cause  them  to  swell.  For 
this  reason  great  care  should  be  taken  to  exclude  everything 
from  the  diet  that  might  give  rise  to  irritation  of  the  bowels. 
They  should  not  be  allowed  to  become  constipated,  for  this, 
also,  is  a  source  of  glandular  engorgement. 

The  abdomen  should  be  swathed  in  flannel,  for  these  ema- 
ciated patients  are  very  easily  chilled.  They  should  be  warmly 
clothed,  and  then  kept  much  in  the  open  air.  They  should  be 
rolled  about  in  an  easy  carriage,  with  an  avoidance  of  sudden 
jars  and  joltings.     If  the  disease  develops  in  a  nursling,  the 


256  THE  DISEASES  OF  CHILDREN. 

quality  of  the  nurse's  milk  should  be  determined,  and  changed 
if  necessary.  If  cow's  milk  is  used  it  should-be  peptonized,  for 
the  digestive  powers  of  the  patient  are  more  or  less  impaired. 
The  wasting  can  be  combated,  to  some  extent,  at  least,  by  in- 
unctions of  olive  oil  or  cocoa  butter.  If  the  abdomen  is  ten- 
der and  painful,  poultices  of  flaxseed  meal  are  to  be  employed. 
Bathing  with  water  should  be  done  sparingly,  and  only  as 
needed  for  the  sake  of  cleanliness. 

Remedies. — The  leading  remedies  for  tabes  mesenterica  are  : 
arsenicum  iod.  ;  arsenicum  alb. ;  argentum  nitras ;  calcarea 
iod. ;  calc.  phos. ;  mercurius  iod.  and  sulphur.  Other  remedies 
than  these  may  be  studied,  but  the  foregoing  should  be  printed 
in  full  capitals  to  properly  emphasize  their  worth. 

The  selection  of  the  particular  one  for  the  case  in  hand  will 
be  successful  only  by  a  close  and  careful  study  of  their  symp- 
tomology,  and  of  the  distinctive  features  of  the  case  itself. 


CHAPTER  IV, 

SCROFULA. 

Definition. — The  word  scrofula  is  almost  obsolete  and  is  so 
indefinite  and  meaningless  that  it  cannot  long  be  retained  in 
the  nosological  list.  A  much  better  term  is  cervical  adenitis, 
or  would  be  if  the  disease  were  confined  to  the  glands  of  the 
neck.  Formerly  the  word  was  used  synonymously  with 
"struma,"  and  was  applied  to  chronic  inflammation  of  the  lym- 
phatic glands,  wherever  situated,  which  showed  a  tendency  to 
spread  by  local  infection  and  prone  to  caseous  degeneration.  A 
scrofulous  individual  was  one  who  was  liable,  from  the  slightest 
exciting  cause,  to  have  enlargement  of  the  glands,  either  of  the 
neck  or  elsewhere,  which  inclined  to  suppuration,  by  reason  of 
defective  power  of  vitality.  The  term  "tubercle"  was  lim- 
ited to  the  gray  granulation  and  caseous  nodules  affecting  the 
lungs,  viscera,  and  serous  membranes.  The  two  diatheses  were 
regarded  as  closely  related,  but  not  identical.  Latterly,  how- 
ever, there  seems  to  be  a  disposition  to  regard  the  two  affec- 
tions as  different  manifestations  of  one  and  the  same  morbid 
process,  and  in  some  recent  works  the  term  scrofula  is  omitted 
altogether.  It  is  not  with  any  disposition  to  revive  or  to  coun- 
tenance a  decaying  bit  of  silly  nomenclature  that  it  is  here  re- 
tained, but  because  it  has  not  as  yet  passed  out  of  use  to  such  an 
extent  but  that  certain  pathological  conditions  of  importance 
to  the  student  and  practitioner  might  be  overlooked  or  neg- 
lected, if  discussed  under  another  name.  Besides,  it  scarcely 
seems  appropriate  in  a  work  of  this  practical  character  to  spend 
either  space  or  type  in  combatting  habits  and  prejudices  that 
are  sanctioned  by  time  and  usage,  and  whose  continued  em- 
ployment can  result  in  neither  confusion  nor  harm.  For  the 
sake  of  explicitness,  and  to  indicate  the  scope  of  the  word 
scrofula  as  here  used,  we  cannot  do  better  than  to  adopt  the 
definition  of  Meigs  and  Pepper  :  "  We,  ourselves,  would  be  un- 
derstood to  employ  it  much  in  the  old  sense,  to  indicate  a  pe- 
culiar constitutional  condition  in  which  there  is  a  'vulnerable' 
or  irritable  state  of  the  lymphatics,  which  renders  them  liable 
to  become  enlarged  from  trifling  causes,  and  at  the  same  time 
indisposed  to  healthy  reparative  action,  and  which  is  also  apt 
to  manifest  itself  by  various  obstinate  chronic  inflammations  of 
D.C.— 17  (257) 


258  THE  DISEASES  OF  CHILDREN. 

the  skin,  mucous  or  synovial  membranes,  or  bones."  It  is  uni- 
versally admitted  that  scrofula  is  intimately  related  to  tubercu- 
losis. It  often  happens  that  the  children  of  tuberculous  parents 
are  scrofulous.  And  it  is  an  unexplained  fact  that  such  chil- 
dren are  scrofulous  and  not  tuberculous.  That  is  to  say,  the 
"  scrofulous  "  child  is  very  subject  to  glandular  swellings,  espe- 
cially of  the  neck,  and  may  have  suppurative  inflammations  of 
the  joints,  and  yet  never  have  any  distinctive  development  of 
other  tuberculous  symptoms — such  as  cough,  emaciation  or  me- 
ningeal trouble.  This  is  not  always  so,  for  persons  who  have 
been  scrofulous  in  early  life,  frequently  become  the  victims  of 
tuberculosis  subsequently.  That  the  two  diatheses,  although 
manifestly  similar  in  many  respects,  are  not  precisely  identical, 
is  shown  by  many  well-recognized  facts.  We  can  here  only 
draw  attention  to  a  very  few  of  them. 

Scrofula  is,  far  more  markedly  than  tuberculosis,  a  disease  of 
early  life.  The  pathological  tendencies  of  the  two  diseases  are 
very  different.  Scrofula  affects,  more  particularly,  the  super- 
ficial glands,  the  bones,  the  skin  and  the  adjacent  mucous  and 
synovial  membranes ;  while  tuberculosis  affects,  by  preference, 
the  serous  membranes,  the  lungs,  the  solid  abdominal  organs, 
and  the  alimentary  and  respiratory  mucous  membranes. 

Causes. — What  has  been  said  relating  to  the  obscurity  that 
surrounds  the  etiology  of  tuberculosis,  is  equally  true  of  the  dis- 
ease under  consideration.  All  of  the  theories  which  have,  from 
time  to  time,  been  brought  forward  to  account  for  its  presence, 
are  but  idle  speculations.  We  shall  probably  not  reach  a  per- 
fect explanation  of  it  until  we  are  able  to  explain  and  under- 
stand life  itself.  What  life  really  is,  constitutes  a  question 
which  is  no  nearer  a  solution  to-day  than  it  was  in  the  very 
beginning  of  time  ;  it  is  only  the  manifestations  of  life  that  are 
observed  ;  its  essence  would  seem,  in  the  very  nature  of  things, 
to  be  undiscoverable.  Scrofula  is  one  of  the  many  things  that 
disturb  and  derange  the  normal  condition  of  life  manifestations, 
and  do  so  in  a  tolerably  regular  and  uniform  manner,  so  that 
when  we  have  a  certain  aggregation  of  symptoms,  we  call  the 
disease  by  this  name,  and  are  able  to  differentiate  it  from 
all  other  diseases.  As  in  the  case  of  other  cachexias,  the  actual 
disease,  while  undoubtedly  hereditary,  is  not  itself  transmitted 
from  parent  to  child,  but  merely  so  strong  a  tendency  to  its 
development  that  in  some  cases  no  care  or  favorable  hygienic 
influences  will  overcome  it.  The  causes  which  tend  to  thus 
develop  it,  act  by  impairing  the  nutrition,  and  include  such 
influences  as  insufficient  and  improper  food,  protracted  expos- 
ure to  damp,  cold  and  especially  to  vitiated  atmospheres,  attacks 
of  certain   diseases,   which,  like   measles,  typhoid    fever  and 


SCROFULA— SYMPTOMS.  259 

chronic  malaria,  exercise  a  remarkably  injurious  action  upon 
nutrition. 

Symptoms. — In  the  majority  of  instances,  symptoms  of  scrof- 
ulosis  appear  in  infancy,  and  usually  the  skin  is  first  affected. 
There  are  various  eruptions,  chiefly  on  the  head  and  about  the 
nates  and  genitals,  which  some  observers  have  thought,  but 
erroneously,  to  be  pathognomonic  of  the  disease.  As  a  matter 
of  fact,  it  would  seem  there  is  little,  if  anything,  in  the  eruption 
itself  to  distinguish  it  from  a  similar  one  inanon-strumous  sub- 
ject. Of  all  forms  of  skin  eruptions,  eczema  is  probably  the 
most  common.  The  eruption  is  tardy  in  development,  runs  a 
slow  chronic  course,  is  very  intractable,  and  is  prone  to  cause 
troublesome  ulcerations  of  the  skin.  It  is  especially  apt  to 
occur  about  the  nose  and  lips,  ears  and  scalp.  The  secretions 
from  the  nasal  mucous  membrane  and  from  the  mouth,  are  apt 
to  excoriate  the  adjacent  skin  and  form  eczematous  sores.  In 
the  same  way  a  chronic  discharge  from  the  ear  may  give  rise  to 
an  eczema  of  the  meatus  and  surrounding  parts,  inconsequence 
of  the  irritating  nature  of  the  discharge.  Scrofulous  eczema 
has  frequently  a  peculiarity  that  may  serve  to  distinguish  it 
from  the  non-scrofulous  variety,  viz.,  the  fluid  which  oozes  out 
is  thick  and  semi-purulent,  instead  of  being  serous,  and  as  it 
dries  it  forms  yellow  crusts.  The  eczema  and  impetiginous 
eruptions,  so  common  about  the  nose  and  mouth  of  weakly 
children,  are  fertile  sources  of  glandular  enlargement.  They 
are  very  obstinate  and  hard  to  cure,  so  long  as  there  is  any  dis- 
charge from  the  nose. 

Affections  of  the  eye  are  very  common,  very  intractable  and 
apt  to  relapse.  They  do  not,  however,  as  a  rule,  lead  to  serious 
damage. 

Catarrhal  inflammation  of  the  middle  ear  is  very  frequent  in 
strumous  children,  and  is  often  associated  with  catarrh  of  the 
eustachian  tube,  and  the  fauces.  More  or  less  deafness  may 
be  produced.  At  a  later  stage  the  discharge  may  become  pur- 
ulent and  affect  the  petrous  portion  of  the  temporal  bone.  The 
membrana  tympani  is  generally  perforated. 

Chronic  enlargement  of  the  tonsils  is  very  common  in  these 
cases,  and  may  occur  in  infants  under  a  year  ;  but  more  often, 
decided  hypertrophy  is  not  noticed  before  the  child  is  two  or 
three  years  old. 

A  catarrhal  state  of  the  mucous  membrane  lining  the  vulva, 
vagina,  and  more  or  less  the  urethra,  is  by  no  means  uncom- 
mon in  strumous  girls  of  two  to  seven  years  of  age.  The  dis- 
charge from  these  parts  which  ensues  is  irritating  and  exceed- 
ingly annoying.  If  considerable,  it  may  be  semi-purulent  or 
bloody.     In  very  young  girls  the  discharge  proceeds  from  the 


260  THE  DISEASES  OF  CHILDREN. 

mucous  membrane  anterior  to  the  hymen,  and  is,  therefore, 
quite  accessible  for  local  treatment. 

Among  the  most  formidable  of  the  affections  of  these  stru- 
mous cases,  are  diseases  of  the  bones  and  joints.  Caries  of  the 
vertebrae  and  of  the  long  bones,  such  as  the  phalanges  of  the 
fingers,  the  ribs  and  the  sternum,  are  common,  and  of  these, 
caries  of  the  phalanges  of  the  hand,  or  metacarpal  bones,  are 
most  so.  These  bone  affections  are  very  rare  in  persons  who 
are  not  scrofulous.  The  synovial  membranes,  especially  those 
of  the  knee  and  hip-joints,  are  very  liable  to  take  on  scrofulous 
inflammation.  When  the  disease  attacks  the  knee,  the  constant 
activity  of  the  joint  usually  precipitates  a  much  earlier  and 
more  active  form  of  inflammation  than  characterizes  the  affec- 
tion when  fixed  glandular  structures  are  alone  involved. 

The  suppurative  action  causes  enormous  swelling  of  the 
joints ;  erosion  and  caries  of  the  osseous  articular  surfaces  su- 
pervene, from  a  consecutive  or  simultaneous  deposit  in  the 
articular  surfaces,  and  their  investing  soft  parts.  Obstinate 
hectic  fever  ensues,  and  the  patient  may  be  considered  fortu- 
nate in  escaping  death  at  the  expense  of  a  permanent  anchy- 
losis of  the  joint.  When  the  hip-joint  is  attacked,  the  case  is 
still  more  painful,  more  serious  and  disastrous  than  in  case  of 
the  knee,  and  recovery  is  slow  and  tedious  at  best,  with  gener- 
ally a  shortened  limb,  and  a  more  or  less  broken  constitution 
for  the  balance  of  life. 

But  the  most  common  of  all  the  lesions  of  scrofula,  and  the 
one  most  characteristic,  is  found  in  connection  with  the  lym- 
phatic glands.  Sometimes  a  single  gland,  but  more  often  several 
of  them,  become  enlarged,  and  after  remaining  swollen  for  a 
longer  or  shorter  time,  suppurate  ;  the  skin  gradually  becomes 
undermined  and  breaks  ;  the  broken-down  glands  discharge,  and 
a  sinus  is  formed,  which  eventually  cicatrees,  after  many  months, 
perhaps  years,  of  chronic  suppuration. 

The  cervical  glands  are  far  more  frequently  affected  than  the 
glands  in  other  regions. 

The  glandular  enlargement,  in  most  cases,  is  very  insidious, 
is  quite  painless,  and  is  free  from  any  local  tenderness.  The 
size  and  situation  of  the  affected  glands  necessarily  vary ;  a 
single  gland  only  may  be  involved,  but  more  often  several 
glands  in  close  proximity  are  enlarged. 

This  enlargement  is  essentially  chronic,  and  the  glandular 
tumor  may  remain  for  months,  readily  seen  and  felt,  but  giving 
the  child  no  inconvenience,  and  without  the  slightest  pain  or 
tenderness.  The  ultimate  result  of  this  enlargement  is  prob- 
lematical. The  gland  may  remain  in  a  swollen  condition  for 
weeks  or  months,  and  then  gradually  the  enlargement  may 


SCROFULA—  TREA  TMENT.  261 

disappear.  Midway  in  the  effort  at  resolution  it  may  take  on 
inflammatory  action,  and  proceed  to  suppurate.  The  older  the 
child  and  the  better  its  general  health,  the  better  the  prospect 
that  the  chronic  glandular  tumor  will  eventually  disappear. 
After  puberty  the  tendency  to  suppuration  is  much  less  than 
in  early  childhood.  The  more  superficial  glands  are  much 
more  liable  to  break  down  and  suppurate  than  are  those  which 
are  deep  seated  in  the  fascia  or  under  it.  The  bronchial  and 
mesenteric  glands  appear  to  suppurate  less  often  than  the  ex- 
ternal glands.  The  axillary  and  the  inguinal  glands  frequently 
enlarge  as  well  as  the  cervical,  but  not  so  often,  nor  do  they 
show  an  equal  tendency  to  suppuration. 

Among  the  exciting  causes  of  glandular  enlargement  vacci- 
nation should  be  mentioned  in  order  to  correct  a  common 
notion,  that  when  such  an  accident  occurs  it  is  the  result  of 
impure  virus.  There  is  no  good  ground  for  such  a  belief,  for 
the  reason  that  even  in  apparently  healthy  subjects,  more  or 
less  tumefaction  of  glands  is  known  to  take  place  when  the 
virus  is  above  suspicion. 

In  cases  of  this  kind  there  is  a  probability  of  a  hitherto  unno- 
ticed strumous  condition,  that  only  required  some  irritant  to 
awaken  it  into  life  and  activity.  On  the  other  hand,  the  subject 
may  be  entirely  free  from  any  such  scrofulous  or  strumous 
taint,  as  explained  elsewhere  (see  Adenitis). 

Prognosis. — In  most  cases  of  scrofula  a  guarded  prognosis 
should  be  given.  Individuals,  especially  children,  who  are  sub- 
ject to  glandular  enlargements  are  always  delicate  and  easily 
upset  by  influences,  that  in  healthier  organizations  would  pass 
unnoticed.  Sometimes,  indeed  often,  these  strumous  cases  get 
along  well,  if  once  the  critical  periods  are  passed.  Dentition, 
and  afterwards  puberty,  however,  are  trying  ordeals  for  these 
cases  to  pass  through,  and  it  must  not  be  forgotten  that  scrof- 
ula is  so  closely  allied  to  tuberculosis  that  the  one  is  very  apt, 
on  slight  provocation,  to  glide  into  the  other. 

Treatment. — The  treatment  of  scrofulosis  naturally  divides 
itself  into  two  stages,  the  stage  of  dyscrasia,  or  predisposition, 
and  the  stage  of  development,  or  of  glandular  affection.  In  both 
stages  the  treatment  must  be  both  hygienic  and  medicinal,  and 
in  case  of  suppuration  operative  measures  are  to  be  added. 

The  principal  indication  of  a  hygienic  nature  is  to  rid  the 
system  and  keep  it  rid  of  all  preventable  sources  of  irritation. 
Scrofulous  children  are  proverbially  cold-blooded,  and  need 
to  be  warmly  clad.  Flannel  should  be  worn  next  the  skin  at  all 
seasons,  or  if  the  skin  is  too  sensitive  for  this,  a  cotton  gar- 
ment may  be  worn  next  the  body,  and  flannel  over  it.  The 
feet  should  receive  extra  care,  and  precautions  taken  to  avoid 


262  THE  DISEASES  OF  CHILDREN. 

getting  them  wet  and  chilled.  Scrofulous  children  do  not  bear 
well  confinement  indoors,  and  should  be  kept  out  in  the  air 
and  sunshine.  Where  it  is  possible,  they  should  be  taken  to 
the  seashore  and  be  allowed  to  go  into  the  sea  water.  The  sea 
air  is  better  than  mountain  air. 

There  is  nothing  new  to  be  said  in  this  connection  with  refer- 
ence to  diet,  except  that  it  should  be  plentiful,  of  proper  qual- 
ity, and  adapted  to  the  digestive  powers  of  the  individual  in 
question,  age  and  development  being  duly  considered.  Chil- 
dren who  have  passed  the  nursing  age,  will  be  benefited  by 
being  given  a  small  quantity  of  cod-liver  oil  two  or  three  times 
daily. 

It  has  long  been  a  common  domestic  practice  to  give  strumous 
children  some  sort  of  fat,  such  as  bacon  or  cream.  They  seem 
to  crave  it,  and  ordinarily  digest  it.  There  is  no  form  of  fat 
equal  to  cod-liver  oil.  It  is  difficult  to  say  just  how  it  acts, 
but  the  consensus  of  the  opinion  of  the  authorities  of  all  coun- 
tries and  of  all  medical  schools  speaks  in  its  favor. 

The  stage  of  development  of  glandular  disease  presents  defi- 
nite indications  for  treatment,  and  the  employment  of  thera- 
peutic measures.  It  is  only  occasionally  that  cases  are  brought 
to  us  soon  enough  to  prevent  glandular  enlargement.  In  the 
majority  of  instances  we  are  face  to  face  with  glands  already 
tumefied,  if  not  inflamed;  and  the  problem  before  us  is  not  one 
of  prevention,  but  relief.  The  object  of  treatment  is  two-fold  : 
first,  to  prevent,  if  possible,  suppuration  or  caseation  ;  second, 
if  this  is  impracticable,  to  secure  a  speedy  and  thorough  evacua- 
tion of  the  gland,  or  what  is  now  an  abscess,  in  order  to  prevent 
the  tubercular  matter  being  carried  to  other  parts.  It  is  not 
always  an  easy  matter  to  determine  the  question  whether  sup- 
puration or  caseation  has  not  already  commenced,  and  pro- 
ceeded so  far  as  to  be  incapable  of  arrest.  Dr.  Gilchrist  says  : 
''  The  presence  of  pus  may  be  suspected,  when  there  has 
been  a  more  or  less  active  inflammation  which  apparently 
subsides  without  a  reduction  of  the  glandular  swelling ;  in  su- 
perficial glands,  fluctuation  can  usually  be  detected ;  in  deep 
structures  the  fact  is  to  be  determined  in  accordance  with  the 
principles  of  surgical  diagnosis. 

"  Suppuration,  therefore,  is  usually  readily  determined.  It  is 
quite  otherwise,  very  often,  in  the  case  of  caseation.  I  believe  that 
in  the  majority  of  instances,  suppuration  antedated  caseation. 
When,  therefore,  there  is  a  history  of  long  duration  of  a  gland- 
ular swelling  coming  on,  with  inflammation,  the  gland  subse- 
quently having  become  smaller,  yet  remaining  notably  enlarged, 
the  swelling  being  firm  but  not  painful,  and  there  having  been 
no  discharge  of  pus,  it  is  altogether  probable  that  caseation  has 


SCROFULA— TREATMENT.  263 

become  established.  So,  also,  on  the  other  hand,  if  we  find  a 
case  in  which  there  is  a  history  of  slow,  painless,  non-inflam- 
matory glandular  swelling,  usually  multiple,  the  glands  being 
quite  firm,  with  a  tendency  to  an  increase  in  the  number  of 
these  enlargements,  caseation  may  be  considered  as  estab- 
lished. 

If  a  case  is  seen  at  the  beginning  of  the  glandular  enlarge- 
ment, its  fate  practically  depends  upon  the  skill  of  the  physi- 
cian. If  he  is  a  master  of  his  calling,  he  can  generally  prevent 
further  development,  if  he  so  wi.shes  ;  if  he  desires  to  promote 
a  destruction  of  the  gland,  he  has  means  to  establish  suppu- 
ration. Some  will  prefer  the  former,  esteeming  it  a  rational 
cure ;  others  prefer  the  latter  method,  desiring  to  eliminate 
what  is  held  to  be  a  concrete  infecting  principle,  which  happy 
circumstances  have  localized  and  placed  in  their  power.  If 
there  is  the  faintest  symptom  of  suppuration,  the  latter  course 
must  be  pursued  ;  without  indications  of  suppuration,  my  opin- 
ion inclines  to  the  former  method. 

To  prevent  suppuration,  reliance  must  be  placed  entirely 
upon  remedies,  and  the  first  in  the  list  will  be  hepar  sulphur 
and  mercurius  vivus,  calcarea  carbon.,  or  baryta  carbon,  as  sec- 
ondary resources.  If  there  is  a  tendency  to  suppuration,  hepar 
sulphur  again  comes  to  the  front,  and  the  question  as  to  the 
employment  of  poultices  comes  up.  Suppuration,  if  too  exten- 
sive, may  precipitate  the  very  catastrophe  which  it  is  desired 
to  avert,  viz.,  the  dispersion  of  the  tubercular  mass.  For  this 
reason,  among  others,  it  is  not  deemed  best  to  use  poultices. 
Sidney  Ringer,  Hartshorne,  Treves,  and  other  writers,  have 
adopted  hepar  sulphur  as  a  remedy  of  the  first  importance  in 
promoting  suppuration,  and  the  former  esteems  it  of  particu- 
lar value  in  the  early  stages  for  its  efficiency  in  suppressing  the 
tendency  to  it. 

Fluctuation  having  occurred,  and  the  evidences  of  the  pres- 
ence of  pus  being  conclusive,  the  tumor  must  be  evacuated. 
To  allow  the  abscess  to  discharge  spontaneously  is  to  insure  a 
large,  ill-looking  scar,  a  very  unnecessary  loss  of  tissue,  and  to 
expose  the  patient  to  the  danger  of  dispersion  of  the  tubercu- 
lar matter.  The  only  question  is  whether  to  open  the  gland 
by  a  free  incision  or  by  aspiration.  The  more  acute  the  abscess, 
the  stronger  are  the  indications  for  free  incision.  In  chronic 
cases,  as  psoas  abscess  {g.  v.),  aspiration  had  better  be  employed, 
or  some  other  method  which  equally  prevents  the  admission  of 
air.  Under  either  circumstance,  however,  incision  or  aspiration, 
owing  to  the  intolerance  of  the  strumous  individual  there  must 
be  no  rough  handling  or  squeezing. 

In  cases  of  caseation,  hepar  may  be  given  to  promote  sup- 


264  THE  DISEASES  OF  CHILDREN. 

puration,  or  a  fine  seton  may  be  passed  through  the  gland. 
When  the  glands  are  superficial,  freely  movable,  with  no  attach- 
ments to  the  skin  or  deep  parts,  enucleation  has  been  practiced 
occasionally  with  very  good  results.  The  skin  is  incised  and 
the  gland  peeled  out ;  if  found  attached,  as  often  occurs,  even 
though  palpation  failed  to  show  such  attachment,  the  attempt 
must  not  be  made.  The  operation  is  a  slight  one,  when  the 
indications  exist,  but  it  may  be  quite  formidable  in  its  results, 
at  least  if  violence  is  used." 

Therapeutics. — The  remedies  most  serviceable  in  scrofula  are 
given  in  their  alphabetical  order,  although  not  in  the  order  of 
their  relative  therapeutic  value.  The  list  is  incomplete,  for 
there  is  scarcely  another  malady  in  which  so  large  a  number  of 
remedies  may  be  needed  in  the  course  of  its  progress.  A  thor- 
oughly complete  list  would  very  nearly  exhaust  the  resources 
of  the  materia  medica. 

Arsenicum. — Some  authorities  regard  this  remedy  as  of  the 
highest  value.  Goullon  says  :  "Arsenicum  does  not  act  directly 
or  specifically  upon  the  morbid  product,  but  upon  the  healthy 
tissue,  the  vital  energy  of  which  it  increases  and  which  it 
enables  to  resist  the  pathological  element.  Restoring  general 
health,  it  becomes  one  of  our  surest  remedies  to  counteract  the 
development  of  neoplasmata."  The  waxy  complexion,  bodily 
restlessness,  weakness,  tendency  to  exhausting  diarrheas  and 
general  aggravation  from  cold,  are  the  more  prominent  indi- 
cations. 

Baryta. — The  symptomatology  for  clinical  purposes  of  the 
carbonates  and  muriate  of  baryta  is  quite  similar,  so  that  the 
drug  is  often  given  in  one  form  or  the  other  indiscriminately ; 
the  muriate,  I  think,  is  generally  preferred,  and  is  credited  with 
a  prompter  action,  and  one  of  longer  duration.  There  is  phys- 
ical and  mental  debility,  with  atrophy,  and  bloated  abdomen. 
The  glands  are  swollen,  hard,  indolent,  and  have  a  tendency  to 
caseation  or  cretaceous  degeneration,  rather  than  suppuration. 
It  seems  to  be  for  those  of  adult  years  what  calcarea  is  to  chil- 
dren. The  face  is  usually  disfigured  by  eruptions  of  various 
kinds,  but  there  is  little  painfulness — at  most  a  soreness  or 
stiffness  of  the  part. 

Belladonna. — This  remedy  is  more  useful  in  cases  of  an  acute 
character,  in  which  the  glands  become  inflamed,  rapidly  suppu- 
rate, and  the  lymphatics  are  seen  to  be  inflamed  by  the  red, 
swollen  streaks  running  to  and  from  the  gland.  There  is  much 
pain  and  heat  in  the  gland,  and  some  considerable  fever ;  the 
pus  is  thick  and  yellow,  and  much  less  in  quantity  than  the 
degree  of  swelling  and  local  disturbance  would  seem  to 
premise. 


SCROFULA— REMEDIES.  265 

Calcarea  Curb. — Malassimilation  ;  tardy  development  of  bony- 
tissue  ;  large  head, with  open  fontanels;  sweating  about  the 
head  and  neck  when  sleeping ;  feet  and  hands  cold  and  damp ; 
the  perspiration  not  smelling  badly,  nor  does  it  make  the  parts 
sore  ;  bloated,  protuberant  abdomen  ;  glandular  swellings  com- 
mon, suppurating  slowly,  without  pain,  and  discharging  thin, 
inodorous  pus,  or  yellow,  bad-smelling,  and  excoriating  pus. 
The  face  is  pale  and  puffy,  the  bowels  easily  deranged;  takes  cold 
on  slight  exposure.  In  fact,  the  remedy  is  the  typical  one  for 
scrofulosis  in  children,  whether  the  disease  be  latent  or  active. 

Even  without  marked  symptoms,  as  above,  the  flabby  skin 
and  the  want  of  firmness  in  the  flesh,  so  often  seen  before  the 
active  development  of  scrofulous  affections,  will  call  for  this 
remedy  above  nearly  all  others.  It  is  also  particularly  useful 
when  there  are  indolent  glandular  swellings,  small  "  kernels," 
as  they  are  called,  with  a  tendency  to  caseation. 

Calcarea  Phosphor. — This  remedy  resembles  the  last,  but 
seems  more  suitable  for  those  who  have  passed  infancy  and 
childhood,  and  are  approaching,  or  have  entered  upon  puberty. 
There  is  emaciation,  a  dirty-white  or  brownish  complexion, 
with  difificult  teething  in  childhood,  and  much  fetid  diarrhea. 
The  deeper  glands  are  oftener  affected,  with  a  particular  ten- 
dency to  enlargement  of  an  abscess  of  the  mesenteric  glands, 
and  to  psoas  abscess. 

Graphites.  —  Eczematous  eruptions,  particularly  about  the 
hairy  parts,  as  the  head ;  red,  scurfy  eruptions  on  the  eyelids, 
with  loss  of  the  eyelashes ;  glandular  swellings,  indolent,  but 
soft,  the  suppuration  being  slowly  established,  the  pus  smelling 
like  brine  ;  the  pus  is  thin,  yellow,  and  excoriating  ;  the  glands 
discharge  through  numerous  fistulas,  and  are  very  slow  in  heal- 
ing. The  formation  of  deep,  sore  fissures  or  cracks,  in  the  flex- 
ures of  the  joints,  particularly  the  fingers,  is  quite  pathogno- 
monic. I  have  seen  them  in  the  groins  of  children,  extending 
quite  through  the  skin,  with  little  soreness  or  inflammation. 

Hepar  SulpJi. — The  symptoms  of  the  dyscrasia  are  very  simi- 
lar to  those  calling  for  graphites,  the  glandular  swellings  run  a 
more  acute  course,  and  suppuration  is  of  a  rather  better  char^ 
acter.  The  chief  indication  for  this  remedy,  and  one  which  no 
other  remedy  seems  to  fill  as  perfectly,  is  to  promote  suppura- 
tion when  once  it  commences  or  seems  inevitable.  In  some  cases 
in  which  I  have  used  it  for  this  purpose,  I  have  been  surprised 
to  find  that  the  action  was  curative,  resolution  occurring  with- 
out suppuration  ;  I  am  utterly  unable  to  tell  under  what  cir- 
cumstances this  action  is  secured  ;  it  has  always  been  unex- 
pected. When  suppuration  threatens  in  a  painfully  swollen 
gland,  a  few  doses  of   hepar   frequently  have   the   effect   to 


2G6  THE  DISEASES  OF  CHILDREN. 

dissipate  the  pain,  and  at  the  same  time  to  wonderfully  hasten 
the  pointing  of  the  abscess. 

lodiiim. — Dark,  scrawny  habit,  extreme  emaciation,  yet  with 
ravenous  appetite ;  general  glandular  enlargement,  the  swell- 
ings not  being  large,  but  hard  and  firm.  When  suppuration 
occurs,  the  pus  is  in  large  quantities,  and  quite  laudable  in  ap- 
pearance. While  small  lymphatic  glands  are  liable  to  tumefac- 
tion, others,  such  as  the  mammae,  are  prone  to  atrophy  and 
disappear. 

Mercurius. — Emaciation  and  dyscrasic  appearance,  with  per- 
spiration on  slight  exertion  ;  painfulness  of  the  bones  and  deep 
parts,  particularly  at  night,  after  going  to  bed.  Malaise  and 
feeling  of  illness  or  prostration,  almost  indescribable. 

Sulphur. — This  is  one  of  our  most  important  remedies  in  the 
dyscrasia  of  scrofulosis.  It  is  rarely  indicated  when  the  disease 
becomes  active.  The  face  has  an  old,  drawn  look;  the  fingers 
are  disfigured  by  hangnails ;  the  soles  of  the  feet  are  so  hot 
that  they  are  kept  uncovered  at  night.  There  is  a  tendency  to 
many  forms  of  chronic,  painless  eruptions ;  the  bowels  are 
always  out  of  order,  either  constipation  or  offensive  diarrhea 
existing ;  nocturnal  enuresis  is  common.  The  prevailing  char- 
acteristic is  mental  and  bodily  indolence. 


CHAPTER   V. 

INFANTILE   SYPHILIS. 

When  syphilis  is  acquired  in  infancy  or  childhood,  its  man- 
ifestations do  not  differ  materially  from  those  of  the  same 
disease  occurring  in  maturity.  With  the  primary  lesion  or 
chancre,  therefore,  the  pedologist  has  nothing  to  do  ;  nor  with 
the  secondary  and  tertiary  symptoms,  as  they  develop  them- 
selves subsequently. 

It  is  only  with  hereditary  syphilis,  as  manifested  before,  or 
soon  after  birth,  that  we  need  concern  ourselves.  As  is  well 
known,  syphilis  is  a  prolific  cause  of  still-births,  premature 
labors  and  miscarriages. 

Occasionally  it  happens  that  the  disease  shows  itself  at  the 
time  the  child  is  born,  but  more  often  an  interval  of  a  few 
weeks,  and  even  several  months,  may  elapse  before  this  occurs. 
When  it  does,  a  rash  makes  its  appearance,  and  certain  symp- 
toms of  unmistakable  import  follow  in  pretty  regular  succession. 

We  do  not  propose  to  enter  into  a  discussion  of  the  vexed 
questions  which  have  given  rise  to  so  much  controversy,  as  to 
modes  of  communication,  order  of  phenomena,  etc.,  etc.  The 
following  facts,  briefly  stated,  are  generally  accepted  by  the 
profession,  and  are  necessary  to  be  understood  because  of  their 
medico-legal  bearing,  and  for  other  reasons  as  well. 

The  disease  may  be  communicated  at  the  moment  of  concep- 
tion by  the  syphilized  condition  of  either  parent. 

A  syphilized  mother  is  supposed  to  communicate  the  disease 
in  a  more  virulent  form  than  the  father,  and  that  blight  and  a 
premature  birth  are  more  likely  to  occur  where  the  mother, 
rather  than  the  father,  is  at  fault.  Both  parties  being  diseased 
at  the  time  of  conception,  blight  and  abortion  are  probable,  if 
not  a  certainty.  Both  parents  may  be  free  from  taint  at  the 
time  of  conception,  and  yet  the  child  be  born  syphilitic  from 
the  mother's  subsequent  contamination,  provided  the  contami- 
nation occurs  prior  to  the  sixth  month  of  pregnancy.  After  the 
sixth  month  the  child  in  utero  seems  to  be  in  less  danger  of 
infection.  If  the  father  alone  is  at  fault  at  the  time  of  con- 
ception, he  may  procreate  a  tainted  offspring,  which  in  turn 
may  contaminate  the  mother,  without  any  primary  experience 
with  the  disease  on  her  part. 

(267) 


268  THE  DISEASES  OF  CHILDREN. 

Parents  recently  syphilized,  though  apparently  relieved  and 
free  from  any  diseased  appearance  at  the  time  of  conception, 
may  propagate  a  syphilized  offspring. 

Physicians  are  often  asked  to  answer  the  question  as  to 
the  precise  date,  or  limit  of  time  beyond  which  such  parents 
may  consider  themselves  reasonably  exempt  from  risk  to  any 
future  offspring,  but  this  question  it  is  impossible  to  answer 
with  certainty.  The  time  varies  in  different  cases.  In  a  gen- 
eral way,  it  may  be  stated  that  parties  lately  syphilized  should 
not  risk  procreation  under  twelve  months  after  the  last  disap- 
pearance of  syphilitic  symptoms.  This  is  only  an  approximate 
rule  and  cannot  be  taken  as  the  limit  of  absolute  safety  in  all 
cases,  for  trouble  may  come  after  a  much  longer  delay,  and  in 
some  cases  there  is  no  safe  period  at  all.  It  should  be  stated 
in  this  connection,  that  the  transmission  of  syphilis  to  the  off- 
spring is  not  inevitable,  when  the  parents,  one  or  both,  have  the 
disease,  and  that  the  aptitude  to  transmit  the  disease  decreases 
spontaneously,  in  many  cases,  with  the  lapse  of  time,  and  this 
tendency  to  spontaneous  diminution  of  the  activity  of  the 
virus  is  greatly  aided  by  intelligent  treatment. 

Symptoms. — As  a  rule  the  specific  symptoms  are  wanting  at 
birth  and  do  not  manifest  themselves  until  from  ten  to  thirty 
days  have  elapsed.  The  infants  are,  to  all  appearances,  well 
born  and  free  from  any  taint  whatsoever.  Oftentimes,  how- 
ever, the  new-born  infant  shows  bad  development,  with  a  dirty 
brown  or  copper-colored  skin,  and  a  scaling  cuticle.  Such  an 
infant  is  apt  to  be  atrophied,  with  a  shriveled  skin  and  features 
pinched  and  old-looking.  In  the  worst  cases,  the  entire  body 
may  be  covered  with  moist  and  brownish  scales  or  crusts,  and 
here  and  there  blebs  containing  serum  or  sero-purulent  matter. 
Such  cases  as  these  take  food  badly  and  generally  die  soon  from 
exhaustion.  The  appearance  just  described  is  called  syphilitic 
pemphigus.  It  presents  itself  first  on  the  palmar  surface  of 
the  hands  and  soles  of  the  feet,  and  subsequently  on  other  parts 
of  the  body.  If  the  eruptive  process  is  delayed  to  a  later 
period,  the  appearances  will  be  the  peculiar  coppery  blotches, 
with  or  without  papular  elevations.  The  mucous  outlets,  such 
as  the  mouth,  the  nose  and  the  anus,  are  apt  to  be  fissured  and 
condylomata  are  common.  The  fissures  or  rhagades  are  very 
painful  and  bleed  when  their  edges  are  put  upon  the  stretch,  as 
in  feeding  or  at  stool.  An  obstinate  and  distressing  coryza  is 
another  symptom  that  is  rarely  absent.  With  it  there  is  a 
nasal  discharge,  more  or  less  copious,  either  thin  and  excoriat- 
ing or  thick  and  muco-purulent,  that  poisons  the  adjacent  skin, 
forming  ugly  sores,  while  it  blocks  up  the  nares  with  thick 
crusts  that  greatly  embarrass  the  respiratory  function.     In  some 


INFANTILE  STPHILIS— PROGNOSIS,  269 

cases  a  combination  of  snuffles  and  cond5'lomata  is  all  there  is 
to  designate  the  affection.  The  coryzal  discharge  is  not  usu- 
ally attended  with  ulceration  of  the  mucous  membrane,  or  not 
to  any  great  extent,  and  necrosis  of  the  nasal  bones  and  hard 
palate  is  rare. 

The  affection  of  the  nares  is  prone  to  extend  posteriorly 
into  the  faucial  and  laryngeal  regions,  producing  mucous  tuber- 
cles and  a  thickening  of  the  mucous  membrane  about  the  epi- 
glottis. Alopecia  is  usual,  embracing  not  only  the  scalp,  but 
also  the  eyebrows  and  tarsal  appendages.  The  earlier  the 
symptoms  are  manifested  in  an  infected  child,  the  more  severe 
is  the  disease.  When  the  symptoms  are  clearly  apparent  at 
birth,  the  case  commonly  proves  fatal  before  many  days. 
Among  the  earliest  symptoms  of  syphilis  is  obstinate  wakeful- 
ness at  night.  The  child  may  be  tolerably  quiet  during  the 
day,  but  as  night  approaches  it  becomes  peevish  and  fretful  and 
cannot  be  induced  to  sleep  except  in  fitful  naps,  from  which  it 
wakens  with  a  start  or  scream.  It  is  supposed  that  this  rest- 
lessness is  excited  by  nocturnal  pains  in  the  bones,  similar  to 
those  affecting  adults. 

Diagnosis. — The  diagnosis  of  hereditary  syphilis  is  not  usu- 
ally attended  with  much  difficulty,  although  in  some  cases  it 
may  be.  The  absence  of  a  rash  cannot  be  considered  decisive 
evidence  either  for  or  against  it.  A  true  syphilitic  rash  is,  at 
times,  so  slight  in  extent  and  mild  in  character,  as  to  attract  no 
attention,  or  it  may  simulate  the  rash  of  one  of  the  eruptive 
fevers,  especially  of  roseola,  so  closely  as  to  breed  confusion. 
When  the  rash  appears  on  the  soles  and  the  palms,  it  has  spe- 
cial significance.  Chronic  snuffling  is  one  of  the  most  reliable 
signs.  If  snuffles  appear  soon  after  birth,  and  continue  for 
weeks  or  months,  the  fact  is  highly  suspicious.  Collapse  of 
the  bridge  of  the  nose,  when  present,  is  another  valuable  sign. 
Enlargement  of  the  spleen,  with  a  tendency  to  marasmus  and 
without  having  had  previous  digestive  trouble,  is  also  a  strong 
count  in  the  indictment. 

Prognosis. — This  is  always  uncertain  if  it  be  not  grave,  but  it 
becomes  less  serious  the  later  the  appearance  of  active  symp- 
toms. The  severity  of  the  nasal  symptoms  is  usually  an  index 
of  the  severity  of  the  disease,  and  complicates  its  nature.  If 
they  are  of  such  a  character  as  to  interfere  with  respiration  and 
nutrition,  they  are  pretty  sure  to  produce,  sooner  or  later,  ex- 
haustion and  death.  The  degree  of  splenic  enlargement  has  a 
strong  bearing  upon  the  prognosis  in  syphilis.  The  majority 
of  cases  die,  wherein  the  spleen  is  greatly  enlarged. 

When  the  infant  survives,  he  may  apparently  throw  off 
all  traces  of  the  disease,  and  grow  up  a  strong  and  healthy 


270  THE  DISEASES  OF  CHILDREN. 

adult.  But  when  the  symptoms  have  been  severe,  more  or 
less  permanent  impression  is  left  upon  the  constitution  and 
various  vicissitudes  constantly  menace  the  progress  towards 
maturity. 

Treatment. — There  is  but  one  remedy  for  syphilis,  whether 
in  child  or  adult,  and  when  that  fails,  hope  may  as  well  be 
abandoned. 

That  remedy  is  mercurius.  The  marked  analogy  between 
the  syphilitic  cachexia  and  the  toxic  effects  of  mercury,  are  so 
obvious  as  to  render  the  curative  relation  of  the  latter  to  the 
former  a  foregone  conclusion  to  any  disciple  of  our  professional 
dogma,  similia,  sitnilibus  curantur.  No  other  drug  in  the  ma- 
teria medica  will  produce  the  same  train  of  symptoms  from  the 
most  trivial  and  superficial,  to  those  which  are  lasting  and  deep- 
rooted  ;  and  no  other  remedy  bears  any  comparison  to  it  for 
direct  curative  power  when  judiciously  administered.  The 
abuse  of  mercury  by  the  old  school  should  not  be  allowed  to 
weigh  against  its  use  in  cases  where  it  is  so  manifestly  applica- 
ble, and  wherein  the  universal  experience  shows  that  for  it,  we 
have  no  analogue. 

As  to  the  particular  preparation  of  mercury,  giving  the  best 
therapeutic  results,  there  may  be  a  diversity  of  opinion.  The 
strong  tendency  to  ganglionic  involvement,  with  nutrient  fail- 
ure, in  syphilitic  infants  would  seem  to  point  to  mercurius  bin- 
iodide,  as  the  one  most  applicable,  and  our  own  experience  is 
confirmatory  of  the  theory. 

It  should  be  given  in  grain  doses  of  the  third  decimal  tritura- 
tion every  four  to  six  hours,  until  improvement  is  noticeable, 
and  then  the  interval  between  doses  should  be  extended  to  ten 
or  twelve  hours. 

Old-school  authorities  recommend  the  introduction  of  mer- 
cury into  the  system  by  means  of  inunction,  and  as  they  have 
many  things  to  learn  of  us,  we  need  not  hesitate  to  learn  from 
them. 

Dr.  Alfred  Post  says :  "  One  of  the  most  satisfactory  methods 
of  treatment  is  inunction  by  means  of  mercurial  ointment, 
diluted  with  an  equal  quantity  of  petrolatum.  With  this  oint- 
ment, a  piece  of  cloth  large  enough  to  cover  in  great  measure 
the  child's  abdomen,  is  thickly  spread  and  placed  under  the 
flannel  bandage.  It  is  renewed  daily,  and  its  position  may  be 
shifted  from  front  to  back,  or  side  as  often  as  any  sign  of  irrita- 
tion appears,  or  regularly  so  as  to  forestall  any  irritation.  The 
movements  of  the  child  serve  to  keep  up  a  slight  friction,  which 
is  sufficient  to  introduce  the  mercurial  into  the  economy.  The 
application  of  the  ointment  by  actually  rubbing  the  skin  with  a 
ball  of  cotton  or  a  swab  covered  by  the  mercurial  is  sometimes 


INFANTILE  SYPHILIS— TREATMENT.  271 

advised,  but  is  a  less  satisfactory  method  than  the  constant 
application." 

The  nutrition  of  syphilitic  infants  requires  attention.  If  it 
is  possible,  the  child  should  be  wet-nursed,  but  the  employment 
of  a  healthy  wet-nurse  for  a  syphilitic  infant,  or  even  for  one 
suspected  of  being  syphilitic,  is  not  justifiable. 

In  case  the  mother  is  apparently  healthy,  though  her  child  is 
syphilitic,  the  child  should  continue  to  be  suckled  by  its  mother. 
There  is  no  reason  to  fear  that  the  child  will  injure  its  mother 
by  so  doing,  in  accordance  with  the  facts  known  as  Colles's  law. 

This  law  briefly  stated  is  as  follows :  Women  who  are  not 
syphilitic  themselves,  but  mothers  of  syphilitic  children,  born 
of  syphilitic  fathers,  possess  an  immunity  as  regards  liability  to 
contract  syphilis  from  the  act  of  suckling. 

This  fact,  which  has  been  enunciated  into  a  law,  was  brought 
into  special  prominence  by  Mr.  Colles  of  Dublin,  who  averred 
that  he  had  never  seen  or  heard  of  a  single  instance  in  which  a 
syphilitic,  breast-fed  child,  deriving  its  infection  of  syphilis  from 
its  parents,  had  caused  an  ulceration  of  the  mother's  breasts, 
whereas,  very  few  instances  have  occurred  where  a  syphilitic 
infant  has  not  infected  a  strange  hired  wet-nurse,  who  had  been 
previously  in  good  health.*  In  cases  where  the  mother  is  her- 
self infected  as  well  as  the  child,  especially  if  her  disease  was 
contracted  shortly  before  or  soon  after  conception,  she  should 
not  attempt  to  nurse  the  infant,  for  the  reason  that  her  milk 
would  be  almost  certain,  as  a  result  of  the  disease,  to  lack  the 
essential  nutritive  properties  for  the  needs  of  the  child.  It 
should  be  placed  upon  a  suitable  artificial  food,  although  the 
chances  of  its  survival  are  thereby  less  than  they  would  be  if 
suckled  by  a  healthy  wet-nurse. 


*  "  Practical  Observations  on  the  Venereal  Diseases,"  1837,  p.  285. 


PA  RT     V- 

THE     ERUPTIVE    FEVERS. 


CHAPTER  I. 

GENERAL    CONSIDERATIONS. 

The  eruptive  fevers  include  measles,  scarlet  fever,  rotheln, 
roseola  and  varicella.  By  some  authors  variola,  or  small-pox 
is  included  in  the  list,  but  we  think  without  reason,  and  it 
is  here  omitted,  because  it  is  not  in  any  sense  an  infantile 
disease ;  and  when  it  does  occur  in  early  life,  it  has  no  features 
or  peculiarities  which  it  does  not  possess  when  afflicting  adults. 
These  fevers  are  sometimes  called  the  exanthemata,  on  account 
of  the  efflorescence  accompanying  them  ;  and  they  are  also 
sometimes  called  the  zytnotic  diseases,  or  were  so  called  when 
all  eruptive  diseases  were  supposed  to  be  caused  by  a  fer- 
ment, "  leaven."  They  are  of  surpassing  interest  to  the 
pathologist,  as  well  as  to  the  medical  student  and  practi- 
tioner, because  of  their  mysterious  origin,  their  widespread 
prevalence  and  their  peculiar  character.  They  differ  from  other 
forms  of  acute  illnesses,  by  being  always  accompanied — when 
given  normal  expression — with  an  extensive  and  characteristic 
eruption  or  rash,  which  appears  at  a  tolerably  regular  stage  of 
the  disease,  remains  visible  for  a  certain  number  of  days  and 
disappears,  leaving  the  cutaneous  epithelium  more  or  less  dead 
and  scaly.  They  have  so  many  characteristics  in  common, 
that  they  may  conveniently  be  studied  as  a  whole  before  point- 
ing out  their  individual  peculiarities. 

They  are  all  diseases  of  early  life,  and  when  adults  are  affected 
by  them,  as  they  sometimes  are,  it  is  the  exception  and  not  the 
rule. 

They  are  thoroughly  democratic  in  their  proclivities,  visiting 
the  rich  and  poor  alike,  and  making  no  discrimination  as  to  sex 
or  color. 

They  are  universally  distributed  over  the  inhabited  world,  no 
nation  or  people,  so  far  as  known,  being  exempt  from  their 
ravages.  They  all  incline  to  appear  at  times  in  an  epidemic 
(272) 


THE  ERUPTIVE  FEVERS.  273 

form,  in  which  case  they  attack  children,  who  have  not  been 
previously  affected,  over  wide  areas  of  country. 

They  rarely  affect  individuals  more  than  once,  and  these 
individuals  thereafter  enjoy  a  complete  exemption  from  further 
attacks,  no  matter  how  much  or  often  they  come  in  con- 
tact with  them.  None  of  these  diseases,  however,  affords  pro- 
tection from  the  others.  All  of  them  are  contagious — some 
only  mildly  so — and  some  of  them  are  both  contagious  and 
infectious.  All  of  them  are  attended  by  more  or  less  fever, 
and  all  of  them  are  accompanied  by  a  rash  which  is  peculiar  to 
itself.  All  of  them  have  a  period  of  incubation,  or  a  period  of 
latency  following  exposure,  during  which  there  are  no  symp- 
toms of  ill  health,  and  it  is  not  until  after  this  period  of  incuba- 
tion, which  differs  in  duration  with  the  different  diseases,  that 
the  peculiar  characteristics  of  the  affection  show  themselves 
and  render  it  possible  to  make  a  differential  diagnosis.  Most 
of  them  are  followed  by  certain  constitutional  effects  in  many 
cases,  which  are  so  constant  as  to  be  called  sequelcB.  All  of 
them  are  varied  or  modified  more  or  less  by  the  year,  the  age, 
constitution,  etc.,  etc. 

Formerly  all  of  these  eruptive  diseases  were  considered  and 
treated  as  modifications  of  one  contagion,  viz.,  variola.  In 
certain  epidemics  of  the  eruptive  fevers,  cases  occur  which  par- 
take so  much  of  the  characteristics  of  two  diseases,  that  a  diag- 
nosis is  very  puzzling.  This  is  particularly  true  of  scarlatina 
and  measles. 

We  have  seen  cases  of  measles  without  prodroma  and  with  a 
sore  throat,  and  in  which  the  rash  was  so  nearly  confluent  as  to 
be  readily  mistaken  for  scarlatina. 

Rotheln  and  measles  are  so  closely  related  that  a  severe  case 
of  the  one  is  almost  indistinguishable  from  a  mild  case  of  the 
other. 

As  a  rule,  however,  each  one  of  these  affections  has  its  dis- 
tinctive features  that  render  it  easily  recognizable.  They  are 
all  self-limited  in  duration. 

The  etiology  of  the  eruptive  fevers  is  very  uncertain.  Their 
contagiousness  is  everywhere  recognized.  The  contagion  of 
one  of  them — scarlet  fever — has  such  vitality  that  it  is  believed 
to  retain  its  infectious  properties  for  many  years.  The  conta- 
gium  of  measles  is  only  mildly  infectious.  Epidemic  influence 
is  undoubtedly  most  largely  responsible  for  the  perpetuity  of 
these  affections. 

In  large  cities  they  are  endemic.    In  New  York  and  Chicago 

there  is  no  month  of  the  year  when  scarlet  fever  and  measles 

are  not  mentioned  in  the  mortality  reports.     In  the  transitional 

periods,  spring  and  fall,  they  are  always  more  prevalent,  doubt- 

D.  C— 18 


274  THE  DISEASES  OF  CHILDREN. 

less  for  the  reason  that  at  such  times  colds  are  numerous,  and 
the  resistant  powers  of  the  system  against  miasmas  is  thereby- 
lowered. 

The  occurrence  of  isolated  cases  of  these  eruptive  fevers  has 
always  been  a  puzzling  phenomenon. 

That  apparently  sporadic  cases  do  occur,  is  a  matter  of  fre- 
quent observation.  The  prolonged  vitality  of  the  scarlet-fever 
poison  has  been  frequently  demonstrated  ;  and  it  is  believed 
that  the  poison  is  so  subtile  and  transmissible,  that  it  may  be 
conveyed  long  distances  in  articles  of  merchandise,  "  even  in 
small  packages,  so  that  those  who  chance  to  open  them  or 
come  in  contact  with  them,  are  infected.  It  is  believed  that 
reading-matter,  transmitted  through  the  mails,  has  in  many 
instances  been  the  medium  of  infection."* 

That  a  contagious  principle  does  exist,  by  means  of  which 
these  different  diseases  are  disseminated  among  communities, 
affecting  now  individuals,  and  again  producing  widespread 
epidemics,  is  clearly  shown  in  the  very  admirable  article  on  this 
subject  by  Dr.  West. 

He  says :  "  Facts,  such  as  the  absence  of  measles  for  the 
period  of  thirty  years  from  the  Cape  of  Good  Hope,  and  its 
development  after  the  arrival  there  of  a  vessel  from  Europe,  in 
which  several  cases  had  occurred  during  the  voyage,  substan- 
tiate the  correctness  of  this  opinion.  The  strongest  proof  of 
it,  however,  is  afforded  by  the  circumstances  in  which  measles 
prevailed  in  the  Feroe  Islands,  in  1846,  after  an  interval  of 
sixty-five  years.  They  were  then  introduced  into  one  of  the 
islands  by  a  workman,  who  leaving  Copenhagen  on  March  20th, 
reached  the  Feroe  Islands  on  the  28th,  apparently  in  good 
health,  but  fell  ill  with  measles  on  April  ist.  His  two  most 
intimate  friends  were  next  attacked,  and  from  that  time  the 
disease  could  be  traced  from  hamlet  to  hamlet,  and  from  island 
to  island,  until  6,000,  out  of  a  total  population  of  7,782,  had  been 
attacked  by  it ;  age  bringing  with  it  no  immunity  from  the 
contagion,  though  the  disease  was  found  to  spare  all  who  in 
their  childhood  had  suffered  from  it  at  the  time  of  the  previous 
epidemic." 

The  closer  commercial  relationship  of  to-day,  between  all 
countries,  which  includes  even  the  most  remote  islands  of 
the  sea,  makes  a  similar  observation  now  impossible.  It  renders 
such  a  fact  as  this  all  the  more  interesting,  and  places  it  in  the 
same  category  of  unique  observations  as  those  afforded  by  the 
fenestrated  stomach  of  Alexis  St.  Martin,  for  the  study  of  gas- 
tric digestion.     It  shows  that  these  eruptive  fevers  are  only 

•J.  L.  Smith. 


THE  ERUPTIVE  FEVERS.  275 

peculiar  to  infancy  and  childhood,  because  few  children  reach 
maturity  without  having  had  them,  and  not  because  there  is  in 
early  life  any  special  or  peculiar  susceptibility  to  their  influence. 
At  least,  it  shows  that  this  is  the  case  with  measles,  and  renders 
it  extremely  probable  that  the  other  affections  of  an  eruptive 
and  contagious  character  are  so  also. 

All  that  can  be  said  at  the  present  day  with  regard  to  the 
etiology  of  these  diseases,  is,  that  each  is  produced  by  and  gives 
rise  to  a  subtle  and  destructive  poison  of  variable  intensity  and 
tenacity,  which  tends  to  perpetuate  itself  by  affecting  suscepti- 
ble persons,  who  may  in  turn  communicate  it  to  others  through 
various  media,  such  as  the  bodily  excretions  and  emanations, 
and  by  contact  and  fomites — the  latter  being,  in  the  judgment 
of  many,  the  chief  source  of  epidemics. 


CHAPTER  II. 

MEASLES  (rubeola:   MORBILLI). 

Definition. — Measles  is  the  most  contagious  of  all  the  exan- 
thems.  It  affects  the  vast  majority  of  mankind  in  all  civilized 
countries.  It  is  an  acute  contagious  and  epidemic  disease, 
commencing  with  all  the  usual  symptoms  of  a  catarrhal  cold, 
having  a  characteristic  rash  which  lasts  from  three  to  five  days, 
and  terminates  with  a  mild  desquamation.  It  is  strongly  epi- 
demic in  its  tendency,  so  that  its  frequency  varies  greatly  at  dif- 
ferent times.  It  attacks  a  far  larger  number  of  people  than  scarlet 
fever,  but  the  mortality  resulting  from  it  is  very  much  less.  It 
is  equally  prevalent  in  both  sexes,  and  but  rarely  affects  nursing 
infants  under  six  months  of  age. 

Mode  of  Infection. — The  contagious  principle  is  most  active 
during  the  catarrhal  stage,  and  continues  in  a  less  active  form 
through  the  stage  of  desquamation.  It  may  be  carried  in  fom- 
ites,  but  not  so  generally  as  scarlet  fever. 

The  stage  of  incubation  is  variable,  lasting  from  five  or  six 
to  twenty  days  or  longer,  with  an  average  of  twelve.  During 
this  period  there  is  nothing  to  indicate  its  presence,  although 
most  authorities  believe  that  the  disease  commences  to  exert 
its  influence  in  the  system  from  the  moment  of  infection,  and 
that  during  the  period  of  seeming  latency,  it  is  gathering  force 
which  finally  breaks  out  into  recognizable  symptoms.  The  ac- 
tivity of  the  contagion  during  the  catarrhal  stage,  when  the 
symptoms  are  those  of  an  ordinary  cold,  and  the  children  so 
affected  are  not  suspected  to  have  measles,  is  one  reason  of  its 
wide  diffusion  through  communities.  At  this  time,  the  cough, 
the  breath  and  the  mucous  secretions  are  all  infectious,  and 
probably  the  emanations  from  the  cutaneous  surface  also. 

Symptoms. — The  disease  is  divided  into  four  stages  :  first,  the 
stage  of  incubation  ;  second,  the  prodromal,  or  stage  of  inva- 
sion ;  third,  the  stage  of  eruption  ;  and  fourth,  the  stage  of  de- 
cline or  desquamation. 

Stage  of  Invasion. — At  a  period,  which,  as  has  already  been 
stated,  is  variable,  the  rubeolous  poison  manifests  itself ;  first 
by  a  catarrhal  inflammation  of  the  mucous  membrane  of  the 
respiratory  organs.  The  symptoms  at  first  are  indistinguish- 
able from  those  accompanying  an  ordinary  coryza.  There  may 
(276) 


MEASLES— STAGE  OF  ERUPTION.  277 

be  shiverings,  headache,  loss  of  appetite,  languor,  and  in  young 
infants,  convulsions.  • 

In  the  majority  of  cases  these  manifestations  are  exhibited 
in  a  mild  degree  only,  and  the  symptoms  are  not  so  grave  as  to 
interfere  with  school  or  pastimes.  There  is  more  or  less 
cough,  at  first  dry  and  tight ;  afterwards  loose  and  rattling.  As 
the  disease  progresses,  these  catarrhal  symptoms  become  more 
pronounced.  The  mucous  membrane  of  the  eyes,  nose,throat, 
larynx,  trachea  and  bronchial  tubes  becomes  involved.  Frequent 
sneezing  and  cough  are  nearly  always  present.  The  conjunc- 
tivas become  reddened  and  congested,  and  there  is  more  or 
less  photophobia  with  lachrymation.  The  discharge  from  the 
nasal  passages,  which  are  inflamed  and  swollen,  is  at  first  thin 
and  watery,  but  soon  becomes  abundant,  thick  and  muco-puru- 
lent  in  character. 

Sometimes  the  cough  becomes  croupy,  and  the  swelling  of 
the  mucous  membrane  of  the  larynx  causes  embarrassment  of 
respiration.  In  rare  and  exceptional  cases  edema  of  the  glottis 
occurs,  and  constitutes  a  dangerous  complication. 

Nausea  and  vomiting  are  often  present,  but  occurring  in  this 
stage  of  the  disease,  do  not,  as  a  rule,  constitute  alarming  symp- 
toms.    Sometimes  there  is  epistaxis. 

The  intensity  of  the  disease  varies  greatly  in  different  epi- 
demics, and  the  severity  of  the  attacks  and  their  complications 
depend  to  a  considerable  extent  on  age,  constitution,  hygienic 
conditions,  season  of  the  year,  and  previous  state  of  health. 
Sporadic  or  isolated  cases  are  usually  milder  than  when  the 
disease  is  prevailing  in  epidemic  form. 

The  fever  which  accompanies  this  stage  is  usually  not 
intense,  and  in  very  mild  cases  may  be  altogether  absent. 

In  severe  cases  the  temperature  may  go  as  high  as  102°,  or 
even  104°  Fahr. 

Stage  of  Eruption. — On  the  third  or  fourth  day  after  the 
catarrhal  symptoms  first  manifest  themselves,  the  eruption 
appears,  showing  itself  first  on  the  forehead,  temples  and 
cheeks,  and  soon  extending  to  the  face,  breast,  trunk  and  ex- 
tremities. From  twenty-four  to  thirty-six  hours  are  occupied 
in  the  development  and  extension  of  the  eruptive  process.  The 
eruption  at  first  appears  in  the  form  of  minute  red  spots, 
resembling  flea-bites,  and  are  coarsely  scattered  over  the  sur- 
face, but  they  rapidly  increase  in  size  and  number  and  become 
distinctly  papular,  with  the  papules  flattened  on  top.  If  the 
tips  of  the  fingers  are  passed  over  the  surface,  the  latter  feels 
uneven  and  rough.  The  papules  incline  to  coalesce  in  the  form 
of  a  half-circle  or  crescent,  and  are  of  a  deep  red  or  purplish 
color.     Between  the  spots,  in  many  places,  are  small  areas  of 


278  THE  DISEASES  OF  CHILDREN. 

skin  of  normal  color.  The  confluence  of  the  papules,  which  is 
more  marked  on  the  face,  neck  and  forearms,  gives  to  these 
portions  of  the  body  a  peculiar  blotched  and  swollen  appear- 
ance. By  the  end  of  the  second  day  of  the  eruption  and  the 
sixth  day  of  the  disease,  the  latter  is  at  its  height.  By  this  time 
the  eruption  has  extended  to  all  parts  of  the  body,  but  is  more 
marked  in  some  portions  than  in  others.  The  fever  does  not 
abate  on  the  appearance  of  the  eruption  ;  both  it  and  the  cough, 
which  were  present  during  the  stage  of  invasion,  continue  with- 
out change,  and  remain  so  during  the  subsequent  two  days,  at 
which  time  the  eruption  begins  to  fade,  the  fever  diminishes, 
and  the  catarrhal  symptoms  decrease.  The  bowels  are  usually 
constipated  in  the  outset,  but  as  the  eruption  subsides  diarrhea 
is  very  apt  to  show  itself. 

Enlargement  of  the  cervical  and  submaxillary  glands  is  not 
uncommon.  The  tongue  is  lightly  coated  throughout  the  dis- 
ease, but  remains  moist.  After  the  eruption  has  lasted  about 
four  days,  or  on  about  the  eighth  day  of  the  malady,  all  of 
the  symptoms  above  described  moderate,  save  one,  and  the 
fourth  or  last  stage  is  reached.  The  only  one  of  the  symptoms 
to  persist  is  the  cough.  The  cough,  which,  as  we  have  seen, 
was  the  first  symptom  to  appear,  is  the  last  one  to  disappear. 
It  sometimes  continues  for  some  weeks  after  all  other  symp- 
toms have  subsided.  After  the  eruption  has  faded  from  the 
surface,  it  may  still  be  seen  for  a  number  of  days  underneath 
the  skin,  to  which  it  gives  a  peculiar  mottled  appearance. 

If  the  child  becomes  overheated  from  any  cause,  this  mottling 
shows  very  plainly.  Notwithstanding  this,  and  in  spite  of  the 
persistent  cough,  the  patient  rapidly  regains  appetite  and  spirits 
and  is  soon  in  ordinary  health.  The  stage  of  decline  is  marked 
by  a  fine  desquamation  of  the  cuticle,  which  continues  sometimes 
for  several  weeks,  but  is  not  so  extensive  and  apparent  as  is 
observed  in  scarlet  fever.  It  is  usually  greatest  where  the 
eruption  was  most  intense. 

Irregular  or  Atypical  Measles. — We  have  described 
measles  as  it  appears  in  its  usual  or  typical  form.  But  it  does 
not  always  pursue  this  regular  course,  and  like  all  of  the  other 
eruptive  diseases,  is  occasionally  seen  lacking  some  one  or  more 
of  its  ordinary  symptoms.  Thus,  we  have  exceptional  cases 
now  and  then,  where  there  is  a  distinct  history  of  exposure  to 
the  contagium  of  measles,  and  in  due  time  an  illness,  which  is 
unmistakably  due  to  this  exposure,  but  in  which  there  is  a 
marked  variation  from  the  ordinary  run  of  symptoms.  We 
may  meet  with  cases  in  which  the  catarrhal  symptoms  are  ab- 
sent, or  present  in  so  slight  a  degree  that  the  disease  is  termed 


IRREGULAR  OR  ATTPICAL  MEASLES.  279 

-jnorbilli  sine  catarrho.  In  such  cases  the  eruption  occurs  with- 
out premonitory  symptoms,  and  with  this  exception,  the  malady 
is  attended  with  the  ordinary  phenomena.  There  are  other 
cases  in  which  the  catarrhal  symptoms  are  well  expressed,  but 
the  eruption  is  scanty  or  entirely  absent.  Such  cases  are  styled 
tnorbilli  sine  exanthemati.  Again,  there  are  cases  where  the 
eruption  remains  on  the  surface  for  an  unusual  period,  or  where 
it  is  much  darker  and  thicker  than  common. 

In  the  latter  case,  the  disease  is  termed  black  or  malignant 
measles.  Here  the  eruption  is  confluent,  and  there  is  extrava- 
sation of  blood  with  great  depression  of  the  vital  forces.  The 
temperature  runs  very  high,  the  pulse  becomes  very  rapid  and 
feeble,  the  extremities  are  cold,  and  the  patient  may  speedily 
drift  into  convulsions  or  coma.  This  type  of  measles  is  very 
fatal,  and  death  may  ensue  before  the  eruption  has  been  fully 
established.  It  occurs  most  frequently  in  cachectic  subjects, 
whose  constitutions  are  more  or  less  racked  or  broken  by  pre- 
vious illnesses,  or  in  crowded  tenements  where  the  surround- 
ings are  peculiarly  bad. 

Complications. — The  course  of  measles  is  very  apt  to  be  com- 
plicated with  some  other  affection  which  is  usually  an  inflam- 
mation of  some  portion  of  the  mucous  membrane,  either  of  the 
respiratory  or  alimentary  tract. 

In  measles,  the  mucous  membrane  is  always  involved,  more 
or  less,  and  the  inflammation  only  constitutes  a  complication, 
when  so  intensified  as  to  give  rise  to  grave  or  dangerous  symp- 
toms. Diphtheritic  inflammation  of  the  fauces  sometimes 
occurs,  and  is  a  serious  complication,  especially  when  it  extends 
into  the  larynx. 

Stomatitis,  of  varying  severity,  is  a  common  attendant  on 
measles,  especially  in  the  very  young,  and  gangrene  of  the 
mouth  may  occur  as  a  complication  or  as  a  sequela. 

When  conjunctivitis  is  attended  with  a  purulent  discharge, 
which  threatens  the  cornea,  it  is  to  be  regarded  as  a  complica- 
tion. Inflammation  of  the  pharynx  may  extend  up  the  eu- 
stachian tube,  and  involve  the  middle  ear,  producing  otalgia, 
catarrhal  inflammation  or  deafness. 

Enteritis  is  a  very  common  complication,  and  is  apt  to  run  a 
protracted  and  dangerous  course. 

The  most  common  and  most  serious  of  the  complications  of 
measles,  are  capillary  bronchitis  and  pneumonia. 

If,  on  the  seventh  or  eighth  day,  when  the  febrile  symptoms 
ought  to  abate,  there  should  be  an  elevation  of  temperature, 
with  the  face  swollen  and  the  lips  dry ;  if  there  be  present  an 
increased  frequency  of  respirations  and  pulse ;  wandering  or 
delirium  during  sleep,  and  especially  if  auscultation  reveals  fine 


280  THE  DISEASES  OF  CHILDREN. 

crepitant  or  subcrepitant  rales,  we  may  feel  sure  that  we  have 
catarrhal  pneumonia  or  capillary  bronchitis  to  deal  with  as  a 
complication.  As  will  be  seen  in  a  succeeding  chapter,  these 
two  affections  are  practically  one  and  the  same  thing — a  dis- 
tinction without  a  difference.  Lobar  pneumonia  will  present 
pretty  much  the  same  train  of  symptoms,  with  the  exception 
that  the  dyspnea  is  not  so  great,  while  the  dullness  on  percus- 
sion is  greater. 

Carditis  and  rheumatism  are  not  uncommon  as  either  com- 
plications or  sequelae. 

Diagnosis. — It  is  usually  difficult,  during  the  stage  of  inva- 
sion, to  discriminate  between  measles  and  an  attack  of  coryza 
or  bronchial  catarrh.  The  history  of  the  case,  if  it  points  to  an 
exposure  to  measles,  may  help  to  the  formation  of  an  opinion  ; 
but  otherwise  the  diagnosis  must  remain  uncertain  until  the 
characteristic  eruption  appears.  Even  then,  the  disease  may 
be  confounded  with  some  one  or  other  of  the  exanthems,  such 
as  rotheln,  scarlet  fever,  variola,  varicella  or  typhoid  fever. 

A  careful  study  of  the  characteristics  of  each  of  these  dis- 
eases will  generally  be  sufficient  to  make  a  diagnosis  clear.  It 
is  best,  however,  in  many  cases,  to  reserve  a  positive  opinion 
until  the  symptoms  have  had  time  to  completely  declare  them- 
selves, meanwhile  exercising  proper  care  to  protect  other  indi- 
viduals from  exposure,  who  have  not  had  all  of  the  exanthems 
previously. 

The  disease  with  which  measles  has  been  most  frequently 
confused  is  probably  variola.  In  the  latter  disease  we  fre- 
quently have  catarrhal  symptoms,  though  usually  less  marked 
than  in  measles.  During  the  first  twenty-four  hours,  the  two 
eruptions  are  very  similar  in  appearance,  but  in  a  few  hours 
more,  the  eruption  in  variola  becomes  beady  and  the  papules 
have  a  distinct  elevation,  which  is  perceptible  to  the  touch 
when  the  hand  is  passed  over  the  surface.  Besides  this,  in  va- 
riola the  active  symptoms  abate  as  soon  as  the  eruption  declares 
itself;  the  pain  in  the  back,  the  fever,  the  headache,  all  disap- 
pear; while  in  measles,  the  fever  and  all  of  the  acute  symptoms 
continue  without  change. 

In  measles,  the  eruption  remains  papular  throughout  its 
course  and  never  becomes  vesicular,  while  in  variola,  the  pap- 
ules soon  become  vesicles,  and  then  pustules. 

In  typhoid  fever  we  have  an  entire  absence  of  catarrhal  symp- 
toms, and  the  petechial  eruption  peculiar  to  it,  and  which 
sometimes  slightly  resembles  that  of  measles,  does  not  appear 
until  the  seventh  day,  while  in  the  latter  disease  it  appears  on 
the  fourth  day. 

Sequelce. — It  is  a  very  common  thing  to  hear  of  some  chronic 


IRREGULAR  OR  ATYPICAL  MEASLES.  281 

derangement  in  patients  we  are  called  to  treat,  as  dating  from 
an  attack  of  measles.  Otorrhea,  strumous  ophthalmia,  en- 
largement or  suppuration  of  the  cervical  glands,  chronic  diar- 
rhea, croup,  tabes  mesenterica,  are  all  recognized  as  liable  to 
follow  in  the  wake  of  measles.  But  they  are  complications 
that  are  largely  avoidable  by  proper  care  and  attention  during 
the  course  of  the  disease  and  during  convalescence. 

It  is  never  safe  for  a  child,  who  has  suffered  from  any  of  the 
eruptive  fevers,  to  be  exposed  to  cold  or  dampness  until  several 
weeks  have  elapsed  after  all  signs  of  the  disease  have  vanished. 
Among  the  sequelae  of  vc\edis\Qs, phthisis  pulmonalisvawst  not  be 
forgotten.  Among  all  the  eruptive  fevers,  there  is  none  so 
prone  to  fire  up  a  latent  dyscrasia  as  measles.  A  child  of  deli- 
cate organization,  in  whom  there  has  been  a  suspicion  of  struma, 
should  be  watched  with  the  greatest  care  while  passing  through, 
or  convalescing  from,  this  disease.  The  greatest  danger  is 
during  convalescence.  An  irregular  thermometry,  after  the 
eruption  has  faded,  should  be  regarded  with  grave  suspicion 
and  frequent  opportunity  should  be  utilized  in  making  a  careful 
examination  of  the  lungs,  in  order  to  detect  the  first  evidences 
of  breaking  down  of  the  lung  structure. 

In  cases  where  there  has  been  considerable  bronchitis  or 
pneumonia,  the  diagnosis  of  incipient  phthisis  will  usually  be 
attended  with  difficulty ;  but  the  dangerous  tendency  of  the 
disease  should  be  remembered  and  every  care  taken  to  avoid 
surprise. 

Prognosis. — In  general,  the  prognosis  in  measles  is  good.  In 
private  practice,  when  the  surroundings  are  wholesome  and  the 
child  can  have  good  care,  and  when  the  disease  occurs  in  a 
patient  of  fairly  good  constitution,  there  is  little  danger  to  be 
feared  ;  but  in  children  of  a  strumous  habit,  or  whose  system  is 
broken  down  by  a  previous  disease,  as  whooping  cough  or 
malaria,  the  disease  is  not  infrequently  attended  with  a  fatal 
issue.  Sometimes  during  epidemics  of  measles,  a  strong  and 
healthy  child  will  be  attacked  by  the  disease  in  a  malignant 
form,  and  will  perish  in  spite  of  every  care  and  attention. 

In  crowded  tenements,  where  but  little  care  of  an  intelligent 
kind  is  given  to  the  sick,  and  where  every  sanitary  law  is  vio- 
lated, measles  is  a  very  serious  and  fatal  malady.  So  too,  in 
camps  where  patients  are  exposed  to  the  vicissitudes  of  the 
weather,  the  disease  is  attended  with  alarming  fatality.  The 
African  race  does  not  endure  the  disease  well.  The  writer  had 
an  extensive  experience  with  colored  people  while  in  the  hos- 
pital at  New  Orleans,  during  the  war  of  the  rebellion,  and  found 
that  measles  was  nearly,  or  quite,  as  fatal  among  them  as 
variola  is  among  the  whites.  They  contract  bronchitis  or  pneu- 


282  THE  DISEASES  OF  CHILDREN. 

monia  very  readily,  probably  owing  to  exposure  and  a  lack  of 
care. 

The  prognosis  is  favorable  in  cases  that  run  an  even  and  reg- 
ular course,  and  is  grave  or  serious  if  complications  intervene, 
such  as  bronchitis,  pneumonia,  diphtheria  or  laryngitis.  Entero- 
colitis and  dysentery  also  add  to  the  danger,  but  do  not  always, 
by  any  means,  portend  a  fatal  issue.  The  continuance  of  fever 
after  the  disappearance  of  the  eruption  always  indicates  a  com- 
plication, and  should  suggest  a  reserved  prognosis.  The  occur- 
rence of  convulsions,  if  at  the  beginning  of  the  eruption  or 
during  the  premonitory  stage,  is  not  a  complication  of  any 
great  moment.  It  does  not  commonly  indicate  unusual  sever- 
ity or  serious  complication.  When  convulsions  occur  later 
in  the  progress  of  the  disease,  however,  they  nearly  always 
point  to  a  fatal  termination. 

Treatment. — The  disease  being  self-limited  in  duration  and 
non-preventable,  when  once  the  contagium  has  been  encount- 
ered by  a  susceptible  subject,  there  is  little  need  of  treatment 
when  it  runs  a  benign  course,  in  a  person  otherwise  healthy. 
It  is  only  in  cachectic  individuals,  whose  systems  are  debilitated, 
or  when  the  natural  course  of  the  malady  is  modified  or  inten- 
sified by  what  are  denominated  "  complications,"  that  drugs 
are  either  useful  or  necessary,  In  cases,  however,  where  the 
pyrexia  is  high  and  attended  by  restlessness,  aconite  may  be 
given.  If  convulsions  threaten,  gelsemium,  cuprum,  veratrtim 
vir.,  ox passiflora  may  afford  relief  ;  if  cephalalgia  is  intense,  bell.; 
if  eruption  is  delayed,  or  only  partial,  bryonia.  For  the  char- 
acteristic cough,  which  is  nearly  always  troublesome,  there  is  no 
remedy  of  equal  value  with  Pulsatilla.  This  drug  is  also  useful 
in  developing  the  eruption,  and  in  controlling  the  irregular  ten- 
dencies of  the  disease,  should  they  be  present.  For  the  ordinary 
diarrhea,  which  is  commonly  present  at  some  stage  of  the  dis- 
ease, no  remedies  are  needed.  It  should  be  allowed  to  pursue 
its  course  unless  excessive  in  duration  or  frequency.  In  the 
latter  case  ipecac,  aloes,  mercurius  or  nux  vomica  may  be  called 
for.  If  the  diarrhea  becomes  dysenteric,  the  usual  remedies 
described  under  that  head  should  be  given.  If  the  cough  does 
not  respond  to  pulsatilla,  but  becomes  dry  and  tight,  give  phos- 
phorus or  tartar  emetic. 

The  throat  affections  and  those  pertaining  to  the  eye  and 
ear  should  be  treated  just  as  the  same  affections  would  be  if 
occurring  idiopathically. 

In  ordinary  cases  the  treatment  required  will  be  more  hygienic 
than  medicinal.  The  temperature  of  the  sick  room  should  be 
maintained  at  nearly  as  possible  at  68°  Fahr.  It  should  not  be 
allowed  to  go  below  65°  Fahr.  nor  above  70°  Fahr. 


IRREGULAR  OR  ATYPICAL  MEASLES. 


283 


If  the  temperature  of  the  body  exceeds  103°  or  104°  Fahr., 
there  is  no  possible  injury  that  can  result  from  a  tepid  sponge 
bath.  The  diet  should  be  bland  and  simple,  and  adapted  to  the 
age  of  the  patient  and  the  condition  of  the  stomach. 

Cooling  drinks  are  perfectly  permissible  and  may  be  acidu- 
lated if  desired. 

The  danger  from  bronchitis  and  pneumonia  should  be  con- 
stantly borne  in  mind,  and  suitable  precaution  taken  to  avoid 
them.  The  danger  from  these  sources  is  not  over  until  conva- 
lescence is  fully  established,  and  the  patient  should  be  restricted 
to  the  house  for  at  least  three  or  four  weeks  after  the  eruption 
has  entirely  subsided. 

The  following  table  of  mortality  from  measles  shows  the 
relative  frequency  of  the  disease  in  this  city  for  eight  years. 

■Comparative  Mortality  of  Measles  in  the  City  of  Chicago  (of 

Children  Under  5  Years  of  age)  by  Quarters,  for  Eight 

Years,  commencing  at  1885,  with  Yearly  Totals. 


Quarters. 

1885. 

18S6. 

1887. 

18S8. 

1889. 

1890. 

1891. 

1892. 

Total 
for  the 
eight 
years. 

Winter 

Spring 

Summer 

Autumn 

20 

28 

24 

4 

13 
28 
51 
34 

145 
149 

38 

9 

9 
40 

52 
50 

96 

77 

5 

17 
12 

38 

102 
102 

41 
20 

22 
37 

412 
478 
284 
246 

Totals  by  yrs. 

76 

126 

341 

151 

204 

72 

265 

.85 

1420 

CHAPTER  III. 

ROTHELN  (GERMAN  MEASLES;   RUBELLA;  FRENCH 
MEASLES). 

Definition  and  History. — Besides  the  synonyms  given  above, 
this  disease  is  blessed  with  many  more.  It  is  called  by  some, 
hybrid,  false  or  bastard  measles ;  roseola ;  morbilli  sine  catarrho ; 
and  it  is  known  also  by  many  other  appellations,  which  are 
needless  to  mention.  This  multiplicity  of  names,  which  would 
be  enough  to  embarrass  a  prince  royal,  is  not  due  either  to 
the  gravity  or  the  dignity  of  the  disease,  but  to  the  uncer- 
tainty which  still  exists  as  to  its  true  nature  and  origin.  So 
late  as  1865,  it  was  by  many  believed  to  be  a  variety  of  measles. 
By  others,  it  was  thought  to  be  a  hybrid  partaking  of  the  nature 
of  both  measles  and  scarlet  fever.  Others,  again,  considered 
it  a  modified  form  of  one  or  the  other  of  these  diseases,  but 
were  uncertain  as  to  which  it  was  most  closely  related.  The 
consensus  of  opinion  now  is,  that  it  is  sui  generis:  a  distinct 
disease  by  itself,  and  in  no  way  related  to  either  measles  or 
scarlatina. 

This  opinion  is  based  upon  the  fact — which  recent  opportuni- 
ties for  study  have  demonstrated — that  epidemics  of  rotheln 
prevail  without  any  regard  to  the  existence  of  cases  or  epidem- 
ics of  either  measles  or  scarlet  fever,  and  that  it  occurs  in  per- 
sons who  have  previously  had  both  of  these  diseases.  It  is 
altogether  probable,  in  cases  of  which  we  hear  or  used  to  hear 
so  often,  of  measles  or  scarlatina  being  repeated  in  the  same 
individual,  that  one  of  the  attacks  was  mistaken  for  the  affec- 
tion under  consideration. 

As  understood  at  the  present  day,  rotheln  or  rubella  may 
be  defined  to  be  a  specific,  epidemic  and  contagious  eruptive 
fever,  at  times  closely  resembling  measles,  and  at  other  times 
more  closely  resembling  scarlatina,  but  having  an  individuality 
of  its  own,  with  peculiar  characteristics,  which  distinguish  it 
from  both  these  diseases.  It  is  a  disease  to  which  children  are 
mostly  susceptible  and  one  attack  of  it  usually  protects  the 
individual  from  a  subsequent  invasion.  Its  most  marked  pe- 
culiarity is  a  prodromal  enlargement  and  induration  of  the  cer- 
vical glands,  without  tendency  to  suppuration. 

Hitherto  the  cases  which  have  been  seen  personally  by  the 
(284) 


ROTHELN.  285 

writer,  have  been  so  mild  and  so  devoid  of  complications  and 
sequelae  as  to  give  him  the  impression  that  the  disease  was  un- 
worthy of  more  attention  or  comment  than  would  be  a  similar 
number  of  cases  of  mild  rubeola.  Even  the  recognized  impli- 
cation of  the  cervical  glands,  has  been  transient  and  unobtrusive, 
and  he  has  never  seen  a  case  where  the  attendant  symptoms 
were  in  any  sense  alarming  or  even  serious.  In  the  spring  of 
1892,  we  had  quite  an  epidemic  of  rotheln  in  Chicago,  and  there 
was  ample  opportunity  to  observe  its  symptoms  and  course ; 
but  all  of  the  cases  in  the  writer's  practice  were  so  mild  that 
but  one  or  two  visits  were  made  to  them  and  no  notes  were 
taken  of  them.  In  a  few  of  the  cases  the  diagnosis  was  in  doubt 
for  a  day  or  two,  owing  to  the  close  resemblance  to  either  mea- 
sles or  scarlet  fever,  but  as  a  rule,  the  cases  were  pretty  clearly 
defined.  There  were  no  fatal  cases,  nor  were  any  of  them 
attended  with  either  sequelae  or  complications. 

Dr.  William  A.  Edwards,*  who  has  made  an  exhaustive  study 
of  the  disease  and  seems  to  have  had  a  very  large  acquaintance 
with  it,  both  in  hospital  and  private  practice,  says  that  in  his 
experience  the  mortality  is  from  four  to  five  per  cent.,  and  that 
this  death  rate  is  largely  due  to  complications.  He  also  states 
that  the  disease  is  more  prone  to  be  epidemic  than  any  of  the 
other  exanthems,  and  a  strong  tendency  to  relapse  is  noted,  in 
which  cases,  the  "  disease  may  manifest  itself  with  all  its  pri- 
mary vigor,  or  it  may  be  attended  by  a  lesser  degree  of  intensity 
of  all  the  symptoms,  particularly  the  prodromal." 

As  an  illustration  of  the  uncertain  and  ill-defined  character 
of  the  disease,  Dr.  Edwards  states  that  the  prodromal  symp- 
toms last  "  from  a  few  hours  to  a  week,"  and  various  authorities 
are  cited  who  state  that  the  eruption  appears  first  on  the  face 
and  neck ;  that  it  is  usually  seen  first  on  the  back  and  chest,  on 
the  breast  and  arms ;  while  others  are  equally  firm  in  the  opin- 
ion that  "it  comes  out  all  over  the  body  at  once." 

According  to  Dr.  Edwards,  the  disease  is  equally  versatile  in 
the  color  and  character  of  the  eruption.  *'  In  my  own  cases," 
he  says,  "  the  rash  was  multiform  in  character,  more  or  less  con- 
fluent, occasionally  ill-defined,  in  color  rosy  or  pale  red.  A  few 
cases  of  the  brightest  scarlet  and  some  purplish  tints  were  ob- 
served. The  rash  was  punctated  ;  small  macules  were  noted ; 
over  the  more  vascular  parts,  the  rash  was  sometimes  elevated, 
producing  a  rough  skin  easily  detected  by  the  touch.  The 
patches  were  very  irregular  in  outline,  shape  and  size,  the  last 
factor  being  the  most  irregular.  The  center  of  each  patch  was 
much  higher  in  color  than  any  other  part.     .     .     .     The  total 


'  Keating's  Cyclopedia  of  Diseases  of  Children,"  vol.  i,  page  684  et  seq^ 


286  THE  DISEASES  OF  CHILDREN. 

duration  of  the  rash  is  much  influenced  by  the  character  and 
type  of  the  epidemic,  and  has  been  variously  reported  by  differ- 
ent observers.  The  average  duration  in  over  two  hundred 
cases  of  my  own,  was  five  days.  In  this  series,  the  shortest  was 
scarcely  two  days,  and  the  longest  of  all  the  cases  was  fifteen. 
.  .  .  Sore  throat  was  always  present  in  my  cases,  and  en- 
largement of  the  tonsils  to  a  great  extent.  Many  of  the  cases 
also  presented  marked  pharyngitis  and  dysphagia. 

"  Enlargement  and  induration  of  the  cervical,  post  cervical  and 
post  auricular  glands,  were  present  during  the  eruptive  stage ; 
occasionally  only  one  or  two  were  affected,  in  other  cases  the 
entire  chain.  This  we  may  consider  one  of  the  most  diagnos- 
tic signs  of  the  disease." 

Diagnosis. — From  what  has  been  said,  it  is  evident  that  a 
disease  which  holds  so  loosely  to  a  type  as  this ;  that  shows 
itself  so  differently  at  different  times  to  the  same  observer,  and 
is  described  so  differently  by  various  authorities,  must  be  at 
times  very  difficult  to  diagnose.  It  is  apparent  that  the  disease 
often  presents  symptoms  very  closely  resembling  measles,  and 
again  very  like  scarlatina.  In  severe  cases  the  complaint  is 
ushered  in  with  shivering  and  febrile  disturbance,  headache, 
pains  in  the  limbs,  sore  throat,  redness  of  the  pharynx  and 
tonsils,  and  in  some  instances  nausea  and  even  vomiting.  In 
addition  to  these  symptoms,  there  is  catarrh,  cough,  sneezing 
and  coryza.  All  of  these  symptoms  are  like  those  of  measles. 
But  there  are  cases  where  the  swelling  of  the  throat  and  tonsils 
and  the  white,  coated  tongue,  followed  by  redness  and  raised 
papillae,  show  a  remarkable  likeness  to  scarlet  fever.  But  the 
premonitory  fever  and  coryza,  instead  of  lasting  three  or  four 
days  as  in  common  measles,  seldom  lasts  more  than  twenty- 
four  hours  before  the  rash  makes  its  appearance.  The  temper- 
ature, even  in  severe  cases,  does  not  range  as  high  as  in  either 
measles  or  scarlatina.  In  the  latter  disease  the  nausea  and 
vomiting  are  common,  in  rotheln  occasional  only.  In  rotheln, 
swelling  of  the  cervical  glands  is  nearly,  or  quite  universal ;  in 
scarlet  fever,  occasional  only. 

The  diagnosis  of  rotheln  is  aided  somewhat  by  its  strongly 
marked  epidemic  character.  Isolated  cases  of  it  are  rare.  This  is 
not  true,  to  the  same  extent  at  least,  of  scarlet  fever.  In  my 
own  experience,  the  eruption  of  rotheln  is  more  scattered  and 
more  of  a  rose  color  than  measles,  and  not  nearly  so  likely  to  be- 
come confluent. 

All  of  the  symptoms  are  of  mild  type,  as  compared  with  the 
diseases  which  it  so  closely  resembles.  The  mild  character  of 
the  attack  ;  the  swelling  of  the  cervical  glands  ;  the  more  rapid 
progress  of   the  disease  from  stage   to  stage  ;  its  presence  in 


ROTHELN.  287 

epidemics  rather  than  in  sporadic  form,  are  generally  sufficient 
to  make  a  diagnosis  fairly  easy,  except  in  rare  instances. 

The  following  letter  from  Dr.  Hedges,  who  has  had  a  very  large 
experience  at  the  Chicago  Half  Orphan  Asylum,  extending 
over  a  great  many  years,  is  inserted  here,  in  order  to  give  em- 
phasis to  what  has  already  been  said. 

My  Dear  Dr.  Tooker — In  reply  to  your  questions  as  to  rotheln 
■would  say — 

(i)   Have  never  had  a  fatal  case. 

(2)  Have  recently  had  a  serious  case — do  not  remember  another. 

(3)  The  enlargement  of  post-cervical  glands  has  lasted  for  sometimes  a 
week  or  ten  days  ;  quite  obstinate,  and  relieved  by  calc.  iod. 

(4)  The  only  pathognomonic  symptom  I  depend  upon  is  the  enlarge- 
ment of  the  post-cervical  and  sub-occipital  glands.  This  occurs  early  in  the 
disease,  often  becoming  a  real  adenitis ;  otherwise  the  slight  or  absent 
catarrhal  symptoms,  paleness  or  brownness  of  eruption,  and  low  fever,  ab- 
sence of  cough,  generally  outlined  the  case,  and  decided  the  diagnosis  in 
my  mind. 

Hope  these  few  notes  may  be  of  some  service  to  you.  Will  say  in  closing 
that  it  took  an  observation  and  experience  oi  years  to  enable  me  to  feel  sure 
that  "German  measles"  was  anything  at  all  different  from  measles 
(rubeola).  So  many  times  we  are  told,  "My  child  has  had  measles,  and 
how  can  he  have  them  again?  "  The  presence  of  a  distinct  and  different 
exanthematous  disease  from  measles  and  very  much  like  it  will  explain 
the  cases  where  they  have  had  it  livice. 

Fraternally,  S.  P.  Hedges 

From  an  interesting  paper  by  Dr.  Charles  W.  Townsend,  of 
Boston,  in  the  Archives  of  Pediatrics,  April,  1890,  we  extract 
the  following  conclusions : 

(1)  Epidemics  of  measles  occur  in  which  many  of  the  cases  exactly  re- 
semble cases  described  as  rotheln. 

(2)  That  these  cases  are  also  found  occasionally  in  severe  epidemics  of 
measles. 

(3)  Thatglandular  swellings  and  sore  throat  are  sometimes  found  in  cases 
of  undoubted  measles,  and  are  sometimes  absent  in  cases  called  rotheln. 

C4)  That  the  symptomology  of  rotheln  is  not  distinct  from  that  of  measles. 

(5)  That  it  is  therefore  impossible  to  make  a  diagnosis  of  rotheln  from  a 
single  case. 

(6)  Thatthe  only  ground  on  which  the  individuality  of  rotheln  rests,  is  the 
fact  that  previous  attacks  of  measles  afford  no  protection  from  this  disease. 

(7)  That  as  second  attacks  of  measles  do  occasionally'  occur,  we  cannot, 
from  our  present  knowledge,  make  the  diagnosis  of  rotheln,  unless — as  in 
the  charterhouse  and  asylum  epidemics — we  meet  with  a  series  of  cases  in 
patients,  many  or  most  of  whom  have  previously  had  measles. 

(8)  That  the  impossibility  of  knowing  how  many  second  attacks  may 
occur  in  a  given  epidemic  of  measles  makes  this  proof  of  the  separate  exist- 
ence of  rotheln  somewhat  problematical,  and  gives  rise  to  the  question,  is  it 
possible  that  in  some  epidemics,  and  not  in  others,  a  mild  form  of  measles 
attacks  equally  those  who  have  had  measles  before,  and  those  who  have  not, 
and  affords  afterwards  no  protection  from  measles?  In  other  words,  is 
rotheln  merely  a  mild  form  of  measles? 


288  THE  DISEASES  OF  CHILDREN. 

Treatment. — But  little  need  be  said  under  this  head.  Ordi- 
narily, the  disease  is  so  mild  and  innocent  that  only  precautions 
need  be  taken  to  prevent  suppression  and  avoid  complications. 
The  same  hygienic  measures  may  be  observed  as  in  measles. 
The  remedies  will  have  to  be  selected  with  reference  to  the 
symptoms  as  they  appear.  Severe  cases  may  require  close 
watchfulness  and  judicious  medication,  but  ordinarily  no  medi- 
cine will  be  needed,  and  none  should  be  given  unless  it  is 
needed.  The  diet  should  be  restricted  to  bland  and  unirritat- 
ing  foods,  and  the  bowels,  if  constipated,  should  be  moved  by 
enemata  or  suppositories. 


CHAPTER  IV. 

SCARLATINA  (SCARLET   FEVER). 

Definition. — Scarlatina  is  an  acute,  contagious  and  infectious 
disease,  having  a  distinct  and  characteristic  eruption,  which  is 
more  or  less  diffused  over  the  entire  surface,  and  is  accom- 
panied, in  all  cases,  with  fever  and  an  angina  of  greater  or  less 
intensity.  It  is  most  prevalent  between  the  ages  of  two  and 
seven  years,  but  no  age  is  absolutely  exempt.  Infants  are 
sometimes  born  with  it  and  the  aged  sometimes  die  with  it. 
Infants  at  the  breast  are  rarely  affected,  although  they  may  be 
in  exceptional  cases.  It  is  strongly  inclined  to  run  an  irregular 
course  and  is  so  often  followed  by  sequelae,  that  its  duration  is 
always  uncertain.  Epidemics  of  scarlatina  are  very  common, 
but  its  epidemic  character  is  not  so  marked  as  either  measles  or 
rotheln. 

Individual  susceptibility  has  much  to  do  with  its  prevalence ; 
and  yet  the  infective  poison  has  such  vital  tenacity  and  such 
diffusability  that  it  may  be  carried  to  long  distances  by  fom- 
ites,  which  may  retain  their  contagious  properties  for  months 
or  even  years.  In  the  intensity  of  its  virulence  it  is  the  most 
variable  and  uncertain  of  all  the  exanthems.  In  all  but  the 
mildest  cases,  the  eruption  is  followed  by  desquamation  of  the 
cuticle. 

History. — According  to  Dr.  Murchison,  "scarlatina"  is  said 
to  have  been  the  vernacular  name  for  the  disease  on  the  shores  of 
the  Levant,  and  was  first  adopted  in  a  medical  work  by  Prosper 
Martianus,  another  Italian  physician,  who,  about  the  middle  of 
the  sixteenth  century,  also  described  the  disease  as  distinct  from 
morbilli.  Epidemics  of  scarlet  fever  were  first  described  in 
England  by  Sydenham,  in  1676,  and  about  the  same  time  in 
Scotland,  by  Sir  Robert  Sibbald,  physician  to  Charles  II.  It 
is  thought  to  have  been  brought  to  this  country  by  means  of 
European  shipping,  about  the  year  1735,  and  from  that  time  it 
has  kept  pace  with  the  westward  progress  of  civilization  until, 
at  present,  there  are  few,  if  any  localities,  in  the  United  States, 
which  it  has  not  invaded. 

Varieties. — There  is  no  disease  with  definite  characteristics, 
which  holds  to  a  type  so  loosely  as  scarlet  fever.  As  a  rule  spo- 
D.C.— 19  (289) 


290  THE  DISEASES  OF  CHILDREN. 

radic  cases  are  mild,  and  even  epidemics  have  occurred  in  which 
all  of  the  cases  were  so  uniformly  mild  that  it  seemed  either  to 
be  losing  its  virulence,  or  that  advanced  methods  of  treatment 
had  shorn  it  of  its  terrors.  Thus  Sydenham,  who  saw  only 
mild  cases,  considered  it  an  "  ailment,"  and  unworthy  the  name 
of  a  "  disease,"  and  Dr.  J.  Lewis  Smith  mentions  the  case  of  a 
distinguished  physician,  of  New  York  City,  who  treated  a  large 
number  of  cases  in  one  of  the  hospitals  without  a  single  death, 
and  a  few  months  later  lost  his  own  son,  who  died  of  a  virulent 
attack  of  the  same  malady.  In  many  cases  the  disease  itself 
seems  to  run  a  simple  and  typical  course,  and  to  be  devoid  of 
danger,  when,  just  as  convalescence  is  begun,  or  seems  to  be 
well  established,  some  of  its  characteristic  complications  or 
sequele  set  in  which  at  once  change  the  prognosis  from  favora- 
ble to  grave  or  hopeless. 

In  other  epidemics — and  these  are  most  common — many  of 
the  cases  run  a  simple  and  discrete  course,  and  terminate  with- 
out serious  sequele ;  while  side  by  side  with  such  cases,  there 
will  be  others  of  the  gravest  character,  which  either  suddenly 
end  in  death  or  leave  the  patient  with  chronic  ailments  of  seri- 
ous nature  and  portent. 

For  these  reasons  it  has  been  found  expedient  to  describe 
the  disease  under  different  classifications,  such  as  regular,  irreg- 
ular and  malignant.  As  this  arrangement  seems  to  be  the 
most  simple  and  plain,  we  shall  adopt  it  and  describe  the  pecu- 
liar features  of  the  affection  under  these  several  headings. 

SYMPTOMS  OF  REGULAR  FORM. 

The  disease  usually  begins  abruptly,  attacking  the  child  in  the 
midst  of  perfect  health.  It  rarely  begins  at  night,  or  exhibits  its 
initial  symptoms  during  the  hours  of  slumber.  More  often  the 
victim  sleeps  as  well  as  usual  during  the  night  preceding  the 
attack,  but  arises  in  the  morning  at  the  usual  time,  with  a  feel- 
ing of  nausea,  which  is  speedily  followed  by  vomiting  or  empty 
retching.  A  fever  of  greater  or  less  intensity  ensues,  and  the 
child  feels  profoundly  ill.  At  this  time  a  careful  inspection  of 
the  fauces  will  generally  discover  an  angina,  and  if  the  child  is 
old  enough  to  explain  its  symptoms,  will  complain  of  pain  on 
swallowing.  In  severe  cases,  where  the  throat  is  principally 
affected,  there  is  danger  at  this  period  of  mistaking  the  disease 
for  a  simple  angina  or  diphtheria.  The  fever,  however,  is  usu- 
ally higher  in  scarlet  fever  than  in  either  of  these  affections, 
while  the  vomiting  is  well-nigh  pathognomonic.  After  a  few 
hours — varying  from  three  or  four  to  eighteen  or  twenty-four — 
the  characteristic  eruption  makes  its  appearance,  first  on  the 


5 CA RLA  TINA ;  SCARLET  FE  VER.  291 

face,  the  forehead,  the  neck  and  breast  and  clavicles.  About 
the  mouth,  the  skin  has  a  peculiar  pallor,  from  the  contracted 
capillaries.  The  eruption  is  fine,  quite  uniformly  diffused  over 
the  affected  surface,  and  is  intensely  scarlet  in  color.  While  at 
a  distance  the  skin  looks  smooth  and  evenly  affected,  a  close 
inspection  shows  it  to  be  finely  punctated,  with  here  and  there 
lines  or  small  areas  of  normal  color.  From  the  face  and  neck 
the  eruption  quickly  diffuses  itself,  so  that  within  twenty-four 
hours,  or  sooner,  it  has  extended  itself  over  the  entire  body. 
The  color  is  not  equally  intense,  however,  being  most  so  over 
the  back  and  buttocks,  and  on  the  inside  of  the  thighs,  where 
the  hue  is  deeply  scarlet.  The  rash  disappears  on  pressure, 
but  reappears  as  soon  as  the  pressure  is  removed.  If  the  finger 
be  drawn  along  the  back  of  a  well-marked  case,  it  will  leave  a 
white  line  in  its  wake,  which  quickly  disappears  as  the  redness 
returns. 

A  tardy  return  of  color  under  these  circumstances  indicates 
a  sluggish  capillary  circulation,  due  generally  to  nervous  de- 
pression, and  is  not  a  good  symptom.  It  is  so  found  in  grave 
cases,  where  the  eruption  is  dull  or  dusky  in  hue.  In  some 
cases  the  eruption  reaches  its  maximum  intensity  during  the 
second  day,  but  in  others  not  until  the  third  or  fourth  day. 
During  the  eruptive  stage,  the  skin  is  dry  and  sensitive  as  well 
as  hot,  and  the  countenance  has  a  puffed  and  swollen  appear- 
ance ;  but  this  is  not  usually  so  marked  as  it  is  in  measles. 
The  tongue  is  generally  coated  from  the  beginning,  but  this 
coating  becomes  more  thick  and  pasty  as  the  disease  progresses, 
until  on  the  second  or  third  day  it  melts  away,  leaving  the  red 
and  swollen  papillae  standing  up  prominently  over  its  surface, 
constituting  the  strawberry  or  mulberry  tongue,  which  is  one 
of  the  pathognomonic  symptoms  of  the  disease.  This  thick 
coating  of  the  tongue  and  its  papillary  studding,  its  quick  melt- 
ing away,  like  snow  in  springtime,  leaving  the  raised  and  red 
papillae,  is  rarely  if  ever  seen  in  any  other  disease,  and  is  so  char- 
acteristic as  scarcely  to  elude  notice.  It  should  be  said,  how-  -  ^ 
ever,  that  this  typical  tongue  is  not  always  so  marked  as  to  be  ^ff/ 
depended  upon  for  diagnosis  in  otherwise  questionable  cases.  -^^^^^^^ 
Like  all  other  features  of  the  disease,  this  one  is  subject  to  all  /7^ 
sorts   of   vagaries,  but  when  present    it    is,  as   before  stated,  '    ' 

'*  pathognomonic." 

The  vomiting  or  empty  retching  is  of  little  or  no  significance 
when  occurring  as  an  initial  symptom.  It  occurs  perhaps  in 
three-fourths  of  all  the  cases,  irrespective  of  gravity,  and  means 
nothing  more  than  a  sympathetic  irritability  of  stomach,  show- 
ing a  derangement  of  the  nerve  centers  of  the  sympathetic  sys- 
tem.    If  this  vomiting  is  persistent,  however,  or  recurs  after 


292  THE  DISEASES  OF  CHILDREN. 

the  eruption  has  manifested  itself,  it  is  a  matter  of  the  gravest 
import. 

It  is  by  no  means  rare  for  convulsions  to  occur,  as  among 
the  first  symptoms  of  scarlet  fever,  especially  with  infants  and 
young  children  of  nervous  temperament.  Convulsions,  like 
vomiting,  occurring  early  in  the  disease,  and  preceding  or  ac- 
companying the  eruption,  are  of  no  special  significance.  They 
do  not  indicate  malignancy,  nor  do  they  point  to  any  special 
complication  in  the  absence  of  other  symptoms,  referable  to 
special  organs.  When  convulsions  either  begin  after  the 
rash  has  made  its  appearance  or  having  begun  earlier,  persist 
after  this  period,  they  are  of  grave  import  and  indicate  a  serious 
poisoning  of  the  nerve  centers.  The  brain  is  not  apt  to  be 
seriously  involved  in  simple  scarlatina. 

Among  the  initial  symptoms,  it  is  common  to  find  dilated 
pupils,  and  an  excited  state  of  the  cerebral  functions.  The 
mind  is  excited  and  in  a  state  of  exhilaration,  in  spite  of  pro- 
found bodily  exhaustion. 

General  physical  weakness  is  the  rule  even  in  mild  cases,  but 
the  mental  condition  varies  greatly  according  to  temperament 
and  previous  state  of  health. 

A  mild  delirium  is  frequently  noticed  during  sleep,  which  is 
quite  peculiar  to  the  disease  and  which,  when  present,  may  help 
to  differentiate  the  diagnosis.  This  delirium  is  most  noticeable 
during  the  first  night  or  two,  and  seldom  lasts  more  than  three 
nights.  It  strongly  resembles  the  "  night  terrors  "  of  childhood, 
and  is  of  only  momentary  duration.  The  child,  for  example, 
wakes  out  of  a  quiet  sleep,  and  for  a  few  moments,  talks  inco- 
herently, fails  to  recognize  its  mother  or  other  attendant,  cries 
and  calls  for  some  person  or  thing  already  within  its  reach.  It 
does  not  seem  to  know  where  it  is;  wants  to  be  taken  home  or 
go  somewhere.  In  another  moment  the  mind  clears  up  and 
after  a  drink  of  water  or  a  sup  of  nourishment,  quiet  sleep  is 
renewed,  to  be  interrupted  again  after  an  interval  of  twenty  or 
thirty  minutes,  by  a  similar  repetition  of  phenomena.  This  de- 
lirium is  quite  characteristic  of  scarlet  fever,  and  is  due  to  an 
excited  or  exalted  state  of  the  cerebrum,  quite  different  from 
that  produced  from  other  forms  of  fever.  The  writer  remem- 
bers distinctly  the  dreams  and  visions  which  accompanied  his 
attack  of  this  malady  when  a  lad  of  twelve  or  thirteen  years 
of  age. 

In  the  simple  as  well  as  in  the  severer  forms  of  scarlet  fever, 
there  is  always  more  or  less  sore  throat.  The  angina  may  be 
slight,  in  the  mildest  cases,  but  it  is  present  in  all.  Without 
sore  throat  there  is  no  scarlet  fever.  There  may  be  but  a 
moderate  exanthem  and  a  severe  angina,  and  the  exanthem 


SCAR  LA  TINA  ;  S  CA  RL  ET  FEVER.  293 

may  be  intense,  and  even  confluent,  with  but  a  moderate  amount 
of  angina ;  but  whichever  predominates,  there  cannot  be  one 
with  an  entire  absence  of  the  other.  The  two  are  absolutely 
necessary  to  constitute  the  simple  or  regular  form  of  the  disease. 
When  the  throat  affection  is  mild  in  the  beginning,  it  usually 
intensifies  as  the  disease  progresses,  and  reaches  its  maxi- 
mum along  with  the  eruption,  subsiding  as  the  latter  subsides. 
The  temperature  is  subject  to  remissions  and  exacerbations. 
In  the  beginning  of  the  disease  it  is  not  uncommon  for  the 
temperature  to  suddenly  rise  to  102°  or  even  to  105°  Fahr., 
and  to  maintain  this  intensity  during  the  period  of  eruption. 
Sometimes  this  elevation  of  temperature  is  reached  at  a 
bound  ;  in  other  cases  it  is  a  gradual  rise,  while  in  either 
case  it  is  apt  to  diminish  gradually  with  the  subsidence  of  the 
rash. 

Some  observers  have  noticed  a  peculiarly  sweet  odor  to  the 
breath  in  cases  of  scarlet  fever,  where  the  throat  affection  has 
been  slight,  but  this  is  probably  imaginary ;  it  certainly  is  not 
marked  enough  to  attract  the  attention  of  many  authorities, 
and  is  surely  not  as  pronounced  as  the  peculiar  bodily  odor, 
which  is  common  enough  in  measles  to  attract  general  notice, 
especially  when  many  cases  are  aggregated. 

The  pulse  is  generally  high  from  the  beginning  to  the  end  of 
the  disease.  It  is  not  unusual  for  it  to  range  as  high  as  140  or 
160,  even  in  mild  cases,  and  this  rate  per  minute  is  frequently 
maintained  throughout  the  eruptive  stage. 

The  urine  is  high  colored  from  the  first,  and  is  usually  scanty, 
even  when  the  kidneys  are  not  perceptibly  affected.  It  is  nec- 
essary, however,  to  keep  close  watch  over  the  urine,  for  even  in 
the  first  few  days,  there  may  be  detected  evidences  of  renal 
catarrh,  which,  if  neglected,  may  eventuate  in  serious  nephritis. 
These  evidences  are  seen  in  mucus  casts,  ephthelia,  debris  and 
blood  corpuscles,  and  traces  of  albumin. 

By  the  second  or  third  day  the  eruption  begins  to  fade  and 
disappear  in  the  order  in  which  it  came. 

The  flush  of  the  face,  which  is  usually  well  marked  in  the  first 
few  hours  of  the  fever,  is  first  to  disappear.  It  is  not  always 
present  even  in  otherwise  well-marked  cases.  The  legs  and 
feet  are  the  last  to  part  with  the  evidences  of  its  presence. 
Desquamation,  or  peeling  of  the  cuticle,  next  follows  ;  but  this 
is  as  erratic  and  uncertain  as  are  all  the  other  phases  of  the  dis- 
ease. Sometimes  desquamation  begins  as  early  as  the  third  or 
fourth  day  of  the  eruption,  but  more  often  it  is  not  perceptible 
until  the  rash  has  entirely  disappeared  from  the  surface.  It 
then  shows  itself  in  furfuraceous  scales  about  the  neck  and  hands 
and  feet.  On  the  palmar  and  plantar  surfaces,  where  the  cuticle 


294  THE  DISEASES  OF  CHILDREN. 

is  thicker,  it  loses  its  furfuraceous  character,  and  is  peeled  off 
in  patches  or  strips.  The  extent  of  the  exfoliations  is,  in 
general,  comparative  to  the  intensity  of  the  exanthem.  When 
the  latter  is  mild,  and  the  skin  soft  and  delicate,  the  scaling  is 
branny  and  slight ;  when  severe,  it  is  lamellar  and  abundant.  A 
repetition  of  the  desquamative  process  has  been  noticed,  in 
which  case  the  skin  remains  in  a  sensitive  condition  for  a  long 
period.  In  any  event,  and  without  regard  to  the  extent  of 
desquamation,  the  skin  is  left  by  the  eruption  in  an  extremely 
sensitive  state,  and  this  sensitiveness  is  shared  also  by  the  kid- 
neys ;  so  that  a  slight  cold  or  exposure  is  apt  to  be  disastrous. 
This  is  equally  true  of  mild  as  of  severe  cases  ;  indeed,  it  is  a 
matter  of  general  observation  that  cases  which  have  been  mild 
and  apparently  devoid  of  danger  in  their  early  stages,  are  the 
very  ones  most  likely  to  go  wrong  in  the  sequelae.  An  explan- 
ation of  this  fact  might  be  sought  in  the  mild  character  of  the 
disease,  and  the  consequent  lack  of  care  which  severer  cases 
would  naturally  receive.  But  this  will  not  explain  the  clinical 
fact  that  mild  cases — even  the  mildest — are  so  often  the  sub- 
jects of  complications  and  sequelae,  and  this  in  spite  of  every 
precautionary  effort.  This  is  more  apparent  in  some  epidemics 
than  in  others.  As  has  already  been  stated,  in  some  years  all 
cases  are  so  mild,  so  regular  and  so  uncomplicated  as  to  mislead 
the  inexperienced  and  the  unwary  into  thinking  that  scarlatina 
is  a  disease  of  but  trifling  character — that  its  dangers  have  been 
overestimated,  or  that  new  methods  of  treatment  have  robbed 
it  of  all  virulence. 

The  fact,  which  has  been  often  exemplified,  that  serious  mis- 
chief may  be  developed  speedily  and  without  warning  even  in 
the  mildest  cases,  and  whether  the  disease  is  sporadic  or  epi- 
demic, should  be  a  warning  to  the  young  physician,  and  should 
make  him  particularly  watchful  and  careful  until  perfect  health 
has  been  fully  established. 


IRREGULAR   FORM. 

The  usual  sequence  of  symptoms,  in  the  regular  or  typical 
form  of  scarlatina,  as  already  described,  is  subject  to  many 
variations,  both  as  to  intensity  and  duration,  without  transcend- 
ing the  limits  of  this  classification  ;  but  peculiarities  of  consti- 
tution, pre-existing  disease,  local  surroundings,  epidemic  influ- 
ences, errors  in  management,  or  other  perturbating  causes  may 
so  disturb  the  natural  or  normal  course  of  the  disease  as  to 
sometimes  render  the  diagnosis  difficult,  or  modify  the  prog- 
nosis in  a  given  case.     The  febrile  phenomena  may  be  greatly 


SCARLA  TINA ;  SCARLET  FE  VER.  295 

intensified  ;  the  exanthem  may  be  either  partial  or  nearly  absent ; 
the  angina  may  be  accompanied  by  ulceration  of,  or  exudation 
on  the  tonsils  ;  nephritis  may  develop  early,  and  be  the  most 
prominent  feature  of  the  disease  throughout  its  entire  course  ; 
the  fever,  while  moderate  in  its  intensity,  may  persist,  without 
any  apparent  cause,  beyond  the  usual  limit  and  be  character- 
ized by  inexplicable  remissions  and  exacerbations.  When  the 
nervous  system  is  greatly  disturbed  in  the  course  of  scarlatina, 
it  may  be  considered  an  irregularity,  for  in  its  simple  form  there 
is  no  such  manifestation.  The  same  may  be  said  of  affections 
of  the  ear  and  the  brain.  Otitis  is  not  by  any  means  a  common 
or  necessary  accompaniment  of  the  disease  in  its  regular  form. 
In  the  irregular  variety,  however,  an  inflammation  may  be 
excited  in  some  portion  of  the  auditory  apparatus,  and  the  me- 
ninges of  the  brain  may  also  be  involved.  The  lymphatic  and 
glandular  structures  are  very  prone  to  become  implicated,  and 
when  this  is  the  case  the  inflammatory  process  may  progress  to 
the  formation  of  abscesses.  When  scarlatina  occurs  in  a  child 
already  affected  with  entero-colitis,  the  eruption  is  apt  to  be 
delayed  or  may  be  suppressed  altogether.  When  entero-colitis 
occurs  in  the  course  of  scarlatina,  it  is  very  sure  to  modify  its 
symptoms  in  one  way  or  another.  If  occurring  early  in  the 
disease,  the  eruption  quickly  recedes,  and  may  not  again  mani- 
fest itself.  Whenever  the  eruption  is  either  delayed  or  sup- 
pressed, or  disappears  prematurely,  and  this  state  of  affairs  is 
accompanied  with  an  aggravation  of  the  fever,  it  constitutes  a 
very  grave  condition. 

At  any  stage  of  the  disease  the  regular  may  be  suddenly 
transformed  into  the  irregular  form,  and  this,  without  any  cause 
with  which  science  is  familiar.  A  case  which  may  have  been 
going  on  in  the  most  straightforward  manner,  with  a  typical 
temperature  and  every  symptom  indicative  of  a  favorable  out- 
come, may  thus  take  on  irregularities  of  one  kind  or  another, 
and  in  a  few  hours  assume  features  of  the  gravest  import.  This 
may  occur  independently  of  any  perceptible  local  affection,  and 
so  far  as  we  are  able  to  judge  may  be  independent  of  any  con- 
stitutional dyscrasia. 

With  our  present  knowledge,  it  is  difficult  to  understand 
these  clinical  experiences,  and  we  can  only  say  that  it  seems  to 
be  due  to  the  perverse  and  erratic  nature  of  the  disease,  irreg- 
ularity and  pathological  surprises  constituting  one  of  its  chief 
characteristics.  It  is  absolutely  impossible  to  indicate  all  of 
the  deviations  and  incidental  derangements  which  may  accom- 
pany an  attack  of  scarlatina.  The  physician  should  under- 
stand this,  and  be  prepared  for  such  emergencies,  however 
suddenly  they  may  arise. 


296  THE  DISEASES  OF  CHILDREN. 

MALIGNANT  FORM. 

Fortunately  this  form  of  scarlatina  is  not  nearly  so  common 
as  those  which  have  previously  been  described.  Some  epi- 
demics are  peculiarly  free  from  malignancy,  all  of  the  cases 
being  comparatively  benign  and  uncomplicated.  In  most  epi- 
demics, however,  there  will  occur  occasionally  one  or  more 
cases  of  such  severity  and  quick  fatality,  that  the  term  "malig- 
nant *  is  the  only  appropriate  designation.  In  such  cases  the 
nervous  phenomena  are  intense  ;  the  initial  symptoms  may  be 
attended  by  convulsions,  which  rapidly  result  in  coma  and 
death.  The  fever  is  high  from  the  commencement,  with  head- 
ache and  delirium.  The  temperature  may  rise  to  105°  or  even 
107°  Fahr.  at  a  bound,  and  continue  at  this  height  for  one,  two 
or  more  days,  when  death  usually  takes  place.  Sometimes  in 
these  malignant  cases,  the  eruption  never  finds  outward  expres- 
sion. The  disease  comes  on  like  an  explosion.  Its  dangerous, 
if  not  fatal  character  is  apparent  from  the  onset.  Some  of  these 
malignant  cases  are  markedly  adynamic  in  character,  great 
exhaustion  of  the  vital  forces  being  an  early  and  conspicuous 
feature.  In  others  the  symptoms  are  most  violent  and  appall- 
ing. In  the  latter,  the  delirium  very  soon  drifts  into  a  fatal 
coma.  In  some  instances  the  stupor  or  coma  is  interrupted  by 
spasms  of  longer  or  shorter  duration.  When  cases,  which  show 
this  malignant  character  at  the  beginning,  do  not  reach  a  fatal 
termination  in  the  first  twenty-four  or  forty-eight  hours,  there 
is  apt  to  be  a  lull  in  the  symptoms  and  a  return  of  conscious- 
ness, with  an  abatement  of  fever  and  a  diminution  in  the  rapid- 
ity of  the  pulse.  Sometimes  this  remission  is  of  permanent 
character,  the  disease  takes  on  a  milder  form  and  health  ulti- 
mately results.  But  more  often,  when  the  initial  symptoms 
have  been  thus  violent,  the  apparent  improvement  is  illusory 
and  temporary.  The  system  is  broken  by  the  virulence  and 
malignancy  of  the  attack  and  the  recuperative  powers  are  inade- 
quate to  withstand  the  shock.  In  some  cases,  after  the  subsi- 
dence of  the  violent  symptoms,  which  marked  the  onset  of  the 
malady,  and  just  as  the  improved  condition  has  stimulated 
hope,  new  phenomena  present  themselves,  which  show  how 
deeply  as  well  as  suddenly  the  scarlatina  poison  has  permeated 
the  system.  These  phenomena  are  manifested  in  severe  inflam- 
mations of  the  fauces,  membranous  deposits  on  tonsils,  or 
inflammation  and  induration  of  the  lymphatic  glands  and  cel- 
lular tissues  about  the  neck  All  of  these  manifestations  are 
more  serious  than  if  occurring  idiopathically,  for  they  are  not 
mere  surface  indications — not  trivial  congestions  of  unimport- 
ant organs,  but  indicate  a  poisoned  state  of  nerve  centers  and 


SCARLATINA;  SCARLET  FEVER.  297 

a  consequent  derangement  of  cell  structure.  There  is  a  fateful 
undermining  of  the  very  center  of  life,  as  if  a  poisonous  flood 
had  swept  over  the  organism. 

When  life  in  these  cases  is  not  instantly  imperiled  or  when 
there  is  an  effort  at  reaction  from  the  nervous  shock,  suffi- 
ciently strong  to  give  opportunity,  this  flood  of  poisonous 
material  is  prone  to  show  itself  in  a  purulent  and  abundant 
coryza  or  in  a  catarrhal  angina,  and  also  in  a  destructive 
otorrhea. 

In  grave  or  malignant  cases  of  scarlatina,  all  of  the  essential 
symptoms  which  constitute  the  disease  are  liable  to  be  intensi- 
fied, or  appear  out  of  their  usual  order  or  sequence.  In  one 
case  the  nervous  phenomena  may  be  paramount ;  in  another  the 
throat  symptoms  may  overshadow  all  others,  constituting  the 
anginose  variety  of  scarlatina  of  some  authors.  In  still  others, 
the  eruption  may  be  so  extensive  and  confluent  as  to  quash 
the  exhalant  function  of  the  skin,  and  thus  produce  the  same 
effect  as  would  result  from  a  burn  of  equal  extent.  Uremia  to 
the  extent  of  intoxication  is  another  of  the  accidents  or  effects 
which  is  liable  to  occur  in  these  cases  of  malignant  disease, 
when  the  kidneys,  instead  of  the  skin,  are  principally  affected. 
It  occasionally  happens  that  a  malignant  case  of  scarlet  fever 
does  not  show  its  malignancy  at  the  outset,  but  starts  off  in  an 
apparently  benign,  but  somewhat  irregular  way,  and  only  takes 
on  a  severe  character  after  several  days  have  elapsed  after  the 
initial  symptoms  have  exhibited  themselves. 

In  these  cases,  however,  there  are  eccentricities  manifested 
that  should  excite  apprehension.  There  is  not  a  full  and  gen- 
eral diffusion  of  the  eruption.  It  appears  in  patches,  and  is 
bluish  rather  than  scarlet. 

There  is  good  ground  for  the  popular  domestic  idea  that 
there  is  safety  in  having  the  "  rash  well  out."  If  the  disease 
does  not  find  full  expression  on  the  external  surface,  it  is  quite 
sure  to  find  it  elsewhere,  on  the  mucous  surface,  or  oftener 
still,  in  the  excretory  glandular  system. 

COMPLICATIONS  AND  SEQUELAE. 

The  dangers  incidental  to  scarlatina  are  not  confined  to  the 
initial  lesions,  nor  are  they  apparent  to  the  closest  scrutiny 
during  the  early  stages  of  the  disease.  The  erratic  nature  of 
the  malady,  and  the  variableness  of  the  symptoms  excited  in  its 
subjects,  are  not  alone  responsible  for  the  terror  with  which  the 
laity  looks  upon  an  invasion  of  scarlatina  into  its  midst.  When 
the  disease  runs  a  mild  course  in  an  otherwise  healthy  child,  it 
means  merely  a  week's  illness  and  a  week  or  so  of  comfortable 


298  THE  DISEASES  OF  CHILDREN. 

convalesence.  Multitudes  of  cases  occur  so  benign  in  character, 
and  so  devoid  of  all  signs  of  danger,  that  one  might,  like 
Sydenham,  think  it  scarcely  worthy  of  consideration.  But  any- 
thing like  an  extensive  experience  with  its  peculiarities  will 
divest  one  of  all  feelings  of  security,  and  confirm  the  general 
feeling  of  dread  and  apprehension  with  which  it  is  everywhere 
encountered.  Severe  cases  are  always  dangerous.  Mild  cases, 
as  already  pointed  out,  are  liable  to  take  on  serious  aspects  at 
unexpected  moments.  But  probably  not  one-half  of  the  mor- 
tality  in  scarlatina  results  from  the  direct  effects  of  the  disease. 
The  other  half  of  the  mortality  can  be  attributed  to  the  effect 
which  the  disease  produces  on  latent  tendencies,  constitutional 
defects,  or  remoter  results  of  the  scarlatinous  poison  on  essen- 
tial organs,  which  were  not  recognizable  during  the  legitimate 
course  of  the  disease. 

Symptoms. — It  has  heretofore  been  stated  that  inflammation 
of  the  faucial  surface  is  a  general,  if  not  necessary  accompani- 
ment of  scarlet  fever.  It  is  possible  that,  as  some  authorities 
state,  cases  do  occur  without  any  evidence  of  throat  affection 
whatever ;  but  to  the  mind  of  the  writer  such  cases  are  very 
questionable,  and  cannot  properly  be  regarded  as  scarlatinal 
unless  indubitable  evidence  is  present  of  exposure  to  the  con- 
tagium  and  other  evidences  are  found  of  distinctive  character, 
on  which  to  found  a  diagnosis.  As  a  rule,  to  which  there  are 
few  if  any  exceptions,  there  is  more  or  less  angina.  It  usually 
precedes  the  efflorescence  on  the  skin,  and  may  sometimes  be 
detected  some  hours  in  advance  of  the  latter. 

In  the  anginose  variety  of  scarlet  fever  the  throat  symptoms 
are  severe.  There  is  pain  on  swallowing ;  the  whole  faucia). 
surface  is  inflamed  and  infiltrated  ;  the  tonsils  are  swollen 
and  painful — usually  more  so  on  one  side  than  the  other,  but 
occasionally  on  both  ;  the  secretions  are  more  abundant  than 
normal  and  are  foul  in  character.  When  the  sore  throat,  how- 
ever mild  or  intense,  appears  in  the  beginning  or  early  stages 
of  the  affection;  it  is  to  be  regarded  as  a  natural  accompaniment 
of  the  disease  ;  but  when,  as  sometimes  happens,  a  true  diph- 
theria is  developed,  with  its  characteristic,  deeply  imbedded 
exudate  and  other  well-marked  features,  it  is  not  a  natural  part 
of  the  malady,  but  is  a  complication  and  one  that  is  greatly  to  be 
dreaded.  So  also  if  the  inflammation,  swelling  and  induration 
of  the  lymphatic  glands  and  cellular  tissues  about  the  neck, 
which  are  among  the  common  accompaniments  of  severe  cases, 
extend  to  the  throat  so  as  to  embarrass  respiration  and  threaten 
edema  of  the  glottis,  such  a  condition  would  be  a  complica- 
tion. In  scrofulous  subjects  the  disease  is  apt  to  be  compli- 
cated by  abscesses  and  by  involvement  of  the  mesenteric  glands. 


SCA  RLA  TINA  ;  SCAR  LB  T  FE  VER.  299 

Purulent  catarrh  of  the  posterior  nares,  otorrhea,  otitis,  syn- 
ovitis, and  endocarditis  are  occasional  complications.  Pleuritis 
is  more  common  than  bronchitis  or  pneumonia. 

Among  the  sequele  of  scarlatina,  dropsy  is  by  far  the  most 
common,  as  a  result  of  acute  nephritis.  It  may  affect  the  serous 
cavities  and  the  internal  organs  and  cause  edema  of  the  lungs, 
ascites,  hydrothorax,  hydropericardium,  or  hydrocephalus  ;  but 
it  is  much  more  apt  to  attack  the  sub-cutaneous  tissues,  when 
it  is  known  as  anasarca. 

It  is  stated  by  most  authorities  that  anasarca  is  present  in 
about  one-fifth  or  one-sixth  of  all  cases,  but  in  the  experience 
of  the  writer  this  is  gross  exaggeration.  We  have  notes  of  fifty- 
three  cases  in  our  case  books,  in  which  dropsy  in  any  form  is 
mentioned  as  complicating  the  disease  in  only  three  instances. 
Anasarca  usually  occurs  in  the  course  of  the  second  or  third 
week  of  the  disease.  It  rarely  shows  itself  before  desquam- 
ation has  begun,  and  more  often  toward  the  end  of  this  process. 
It  follows  mild  or  moderate  more  often  than  severe  cases, 
and  is  commonly  attributed  to  the  influence  of  cold;  but  this  is 
probably  an  erroneous  opinion,  for  it  happens  quite  as  often  as 
otherwise,  in  cases  where  every  precautionary  measure  has  been 
taken.  It  is  doubtless  due  to  changes  in  the  kidneys,  induce^ 
by  some  peculiarity  in  the  scarlet-fever  poison.  Just  how  these 
changes  are  produced  and  why,  are  questions  hard  to  answer. 
When  the  kidneys  are  examined  directly  after  a  dropsy  has 
occurred,  they  are  found  congested,  the  uriniferous  tubules 
are  in  a  catarrhal  condition  and  an  epithelial  desquamation  more 
or  less  extensive  is  in  progress. 

Occasionally  a  croupous  inflammation  of  the  tubules  is  no- 
ticed. The  morbid  processes  commence  at  the  malphigian 
bodies,  and  extend  to  the  uriniferous  tubules.  Cloudy  swell- 
ing of  the  epithelial  cells  characterizes  the  anatomical  changes 
during  the  first  week.  Infiltration  soon  takes  place  around  the 
tubules,  which  become  stuffed  with  these  clouded  and  enlarged 
epithelial  cells,  or  with  granular  matter,  resulting  from  their 
disintegration.  Sometimes  abscesses  form  in  the  substance  of 
the  kidney  (kippox).  The  first  noticeable  indication  of  nephri- 
tis is  a  puflfiness  of  the  eyelids;  and  soon  after  the  face  takes 
on  a  puffed  and  bloated  look.  From  the  face  it  extends  over 
the  body,  and  if  the  anasarca  becomes  general,  it  is  apt  to  be 
attended  by  more  or  less  ascites. 

Previous  to  the  appearance  of  dropsical  symptoms,  there  is 
usually  an  exacerbation  of  the  fever.  There  is  anorexia,  rest- 
lessness, and  perhaps  nausea  and  vomiting.  The  urine  becomes 
high-colored  and  scanty,  and  if  critically  examined,  will  be 
found  to  contain  albumen  and  exudative  casts.     It  should  be 


300  THE  DISEASES  OF  CHILDREN. 

remembered  that  the  great  danger  from  scarlatinous  nephritis 
lies  mainly  in  the  failure  to  discover  its  presence,  until  grave 
symptoms  appear.  The  urine  of  a  child  sick  with  scarlatina 
should,  if  practicable,  be  examined  daily  as  to  its  quantity,  spe- 
cific gravity,  and  a  frequent  test  for  albumin  should  be  made. 
Diminution  in  the  quantity  of  urine  generally  precedes  both 
the  albuminuria  and  the  dropsy,  although  both  are  apt  to 
follow  quickly  thereafter. 

If  the  early  symptoms  of  a  renal  catarrh  be  overlooked  or 
neglected,  it  may  speedily  become  a  serious  compHcation,  while 
if  recognized  in  its  incipiency,  it  is  usually  very  amenable  to 
treatment. 

In  some  cases  the  urinary  secretion  is  totally  suppressed, 
and  then  the  dropsy  makes  rapid  progress ;  there  is  more«or 
less  headache,  sudden  and  marked  elevation  of  temperature, 
vomiting  more  or  less  persistent,  and  finally  convulsions,  coma, 
and  in  all  probability,  death.  The  convulsions  may  be  clonic 
or  tonic,  partial  or  general. 

In  mild  cases,  where  the  urinary  secretion  is  only  partially 
suppressed,  and  prompt  measures  are  employed  to  relieve  the 
local  congestion,  the  anasarca  begins  to  decline  after  two  or 
three  days,  the  untoward  symptoms  disappear,  and  the  urine 
becomes  normal. 

Diagnosis. — In  the  majority  of  cases,  the  diagnosis  of  scarlet 
fever  is  not  attended  with  difficulty.  It  is  only  in  exceptional 
cases,  occurring  in  the  absence  or  incipiency  of  an  epidemic, 
and  where  the  initiatory  symptoms  are  ill-defined,  that  a  mistake 
is  likely  to  occur.  A  sudden  attack  of  fever,  especially  if 
occurring  in  the  morning,  with  more  or  less  angina,  is  always 
to  be  looked  upon  with  suspicion.  If  the  disease  is  prevalent 
in  the  neighborhood,  or  if  there  is  any  history  to  be  had  of 
exposure  in  a  susceptible  subject,  there  need  be  little  ground 
for  doubt.  This  is  especially  true  of  the  mild  or  regular  form  of 
the  disease. 

In  the  irregular  form,  especially  when  the  exanthem  is  scanty, 
the  angina  will  surely  be  present,  and  so  also,  the  vomiting  and 
the  fever. 

The  tongue  rarely  fails  to  show  its  characteristic  coating 
which  when  present,  is  pathognomonic. 

Doubtful  cases  occasionally  occur,  in  which  cervical  lymphad- 
enitis or  a  mild  nephritis  constitutes  the  entire  picture.  Ab- 
sence of  the  prodromal  stage;  presence  of  the  strawberry 
tongue ;  the  early  appearance  of  the  eruption  and  its  finer 
character,  will  serve  to  distinguish  scarlatina  from  measles. 
The  coryza  and  the  cough  are  natural  accompaniments  of 
measles,  but  not  of  scarlatina.     In  rotheln  or  German  measles. 


SCARLATINA;  SCARLET  FEVER.  301 

the  eruption  is  scattered,  there  is  no  angina,  and  the  constitu- 
tional symptoms  are  relatively  very  mild.  Erythema  and  rose- 
ola sometimes  closely  resemble  scarlatina,  but  both  lack  the 
characteristic  tongue,  the  angina  and  the  glandular  complica- 
tions. In  both  the  former  affections  the  exanthem  is  more  local 
and  confined  to  certain  portions  of  the  body,  while  the  scarla- 
tinous eruption  is  more  extensive  and  more  equally  diffused. 
A  few  hours  will  suffice  to  dissipate  all  doubt  in  these  simili- 
tudes. 

Scarlatinous  dropsy  is  easily  distinguished  by  its  acute 
course,  by  its  beginning  about  the  face  and  thence  extending 
to  the  serous  cavities,  and  by  its  occurring  in  children,  during 
or  subsequent  to  an  attack  of  the  fever.  A  previous  or  accom- 
panying desquamation  and  associate  enlargement  of  cervical 
glands  will  still  further  assist  the  diagnosis. 

For  the  differential  diagnosis  the  reader  is  referred  to  the 
close  of  the  chapter  on  Roseola. 

Prognosis. — The  prognosis  in  scarlet  fever  should  always  be 
guarded.  It  is  largely  influenced  by  the  type  of  the  prevailing 
epidemic,  the  character  of  the  attack,  the  vigor  and  age  of  the 
patient,  and  more  especially  by  the  presence  or  absence  of  serious 
complications. 

The  development  of  scarlatinous  nephritis  is  not  necessarily, 
even  in  its  graver  forms,  a  fatal  complication.  If  recognized 
before  renal  degeneration  has  gone  beyond  restoration,  there  is 
no  reason  to  abandon  hope.  Many  of  these  cases  recover,  even 
after  convulsions  have  occurred.  At  the  same  time,  clinical 
experience  teaches  us  that  all  nervous  disturbances,  and  all  in- 
flammatory complications  increase  the  danger  of  the  disease. 
The  most  trivial  complication  may  quickly  alter  the  aspect  of 
the  case,  and  change  the  prognosis  from  favorable  to  unfavor- 
able. A  temperature -rising  rapidly  to  105°  Fahr.,  or  continuing 
for  a  length  of  time  at  or  above  this  figure,  especially  after  the 
beginning  of  desquamation,  is  unfavorable.  Pyemia  and  sep- 
ticemia are  usually  fatal.  Abundant  hemorrhagic  extravasa- 
tions, hematuria,  and  evidences  of  the  hemorrhagic  diathesis, 
are  always  signs  of  an  unfavorable  prognosis. 

Favorable  symptoms  are  :  a  temperature  below  104°  Fahr. ;  a 
pulse  not  exceeding  one  hundred  and  twenty  beats  per  minute  ; 
the  absence  of  serious  cerebral  and  throat  symptoms ;  a  fully 
and  regularly  developed  rash  of  a  bright  scarlet  color,  and  a 
copious  flow  of  non-albuminous  urine. 

Duration, — In  mild  and  uncomplicated  cases  the  duration  of 
the  febrile  stage  of  the  disease  is  from  five  to  seven  days.  In 
very  mild  cases  it  may  be  even  less  than  this.  But  even  in 
such  exceedingly  mild  cases  there  is  no  security  until  after 


302  THE  DISEASES  OF  CHILDREN. 

several  weeks  have  passed,  and  the  patient  cannot  be  consid- 
ered as  out  of  all  danger,  until  some  time  after  all  evidences  of 
desquamation  have  vanished.  Some  years  ago  the  New  York 
State  Board  of  Health  addressed  a  circular  to  the  more  promi- 
nent physicians  of  New  York  City,  asking  them  how  long  before 
a  pupil  having  had  scarlet  fever  should  be  permitted  to  return 
to  school.  The  answers  returned  varied  from  six  to  eight 
weeks.  For  the  shorter  period  at  least,  the  child  recovering 
from  scarlatina  should  be  restricted  in  its  intercourse  with  other 
children,  and  should  be  more  or  less  under  observation  and  care. 

Mortality. — Scarlet  fever  is  universally  regarded  as  the  most 
fatal  of  all  the  exanthematous  diseases.  Unfortunately  for 
statistics,  there  is  no  strict  law  in  this  country  compelling  phy- 
sicians to  report  their  non-fatal  cases  of  any  of  the  contagiums. 
In  the  large  cities  a  faithful  record  is  kept  of  all  fatalities,  but 
the  relative  mortality  in  a  given  disease  is  mere  guess-work. 
In  the  epidemic  of  scarlet  fever  which  visited  Chicago  in 
1876-7,  there  were,  during  fourteen  months,  eleven  hundred 
and  thirty-eight  (1138)  deaths  from  this  cause.  From  the 
number  of  cases  of  the  disease  reported  to  the  health  oflficer, 
Dr.  DeWolff,  who  was  then  commissioner  of  health,  estimated 
there  must  have  been  within  the  city  limits,  during  these  four- 
teen months,  from  ten  thousand  to  twelve  thousand  cases, 
which  would  give  a  mortality  of  about  ten  per  cent.  This  is 
about  the  usual  estimate  in  severe  epidemics  of  wide  extent. 
Dr.  Charles  W.  Earle,  of  this  city,  who  studied  this  epidemic 
very  carefully,  endeavored  to  verify  or  correct  these  statistics 
by  getting  the  number  of  cases  treated  by  the  leading  physi- 
cians. He  estimated  the  number  of  cases  as  not  less  than  four- 
teen thousand.  If  his  figures  are  approximately  correct  they 
would  reduce  the  mortality  to  about  eight  per  cent.  The  mor- 
tality in  sporadic  or  widely  scattered  cases  is  always  less  than 
in  epidemics  and  less  in  the  country  than  in  the  city.  It  is 
always  greater  in  hospitals  and  asylums  than  in  private  practice. 
It  varies  greatly  with  seasons  and  with  the  circumstances  of  life. 

In  the  regular  form  death  is  generally  due  to  some  compli- 
cation. 

The  young  physician  cannot  be  too  strongly  impressed  with 
the  fact  that  scarlet  fever,  pure  and  simple,  is  a  mild  and  self- 
limited  disease,  but  at  the  same  time  it  is  the  most  treacherous, 
the  most  uncertain,  variable  and  dangerous  of  all  the  exanthems. 
Constitutional  defects  are  especially  liable  to  be  developed  and 
cause  trouble  in  the  course  and  particularly  after  the  disease 
has  apparently  spent  its  force,  and  all  symptoms  seem  to  be 
satisfactory.  In  a  word,  the  sequelae  are  ever  and  always  to 
be    more    dreaded    than    the    disease    itself — and    vet    these 


5  CA  RLA  TINA  ;  SCARLET  FE  VER. 


303 


sequelae  may  often  be  controlled,  if  not  prevented,  by  early 
recognition  and  prompt  treatment. 

The  following  table  of  mortality  from  scarlet  fever,  in  this 
city,  is  not  without  interest. 

Comparative  Mortality  in  the   City  of   Chicago    from   Scarlet 
Fever  (in  Children  Under  5  Years  of  Age)  by  Quar- 
ters, for  the  Eight  Years  beginning  1885,  with 
Yearly  and  Quarterly  Totals. 


Quarters. 

1885. 

18S6. 

1887. 

18S8, 

1889. 

1890, 

i8qi. 

1892. 

Total 

for 
Quar- 
ters. 

Winter 

Spring 

Summer 

Autumn 

75 
70 

70 
64 

46 

66 
39 

57 
28 

41 
50 
41 
52 

51 
55 
39 
40 

74 
42 

30 

47 

160 

108 

81 

150 

152 
99 
53 

78 

689 

527 
3S6 

530 

Totals  by  yrs. 

279 

220 

190 

184 

X85 

193 

499 

382 

2132 

Prophylaxis. — Every  case  of  scarlatina,  however  mild,  is  both 
contagious  and  infectious,  and  the  attending  physician  will  not 
have  discharged  his  full  duty  in  a  given  case,  until  he  has  taken 
every  warrantable  precaution  against  the  further  spread  of  the 
disease.  During  the  first  few  days  after  the  attack,  the  disease 
is  only  mildly  infectious.  By  some  it  is  maintained  that  it  is 
only  so  after  desquamation  has  begun.  The  safest  way  is  to 
guard  against  dissemination,  as  soon  as  the  nature  of  the  mal- 
ady has  been  clearly  recognized.  To  this  end,  the  patient 
should  be  rigidly  isolated  ;  and  if  possible,  a  light  and  well- 
ventilated  room  on  the  top  floor  of  the  house  should  be  selected 
for  the  temporary  hospital,  or  in  case  of  an  apartment,  the 
room  should  be  the  one  most  quiet  and  free  from  intrusion. 
This  room  should  be  stripped  of  all  superfluous  furniture.  Car- 
pets, rugs  and  hangings  should  be  removed,  leaving  only  those 
things  that  are  considered  absolute  necessities.  The  bedding 
and  linen  should  be  chosen  with  reference  to  their  destruction 
after  they  cease  to  be  needed.  Only  such  books  and  play- 
things should  be  allowed  to  remain  as  can  be  burned  ultimately. 
The  patient  should  be  anointed  daily  or  oftener  with  some 
unctuous  substance,  so  as  to  fix  the  dusty  particles  of  the  exfoli- 
ating epidermis  during  desquamation  and  to  prevent  their  being 
widely  disseminated.  For  this  purpose,  olive  oil  is  as  good  as 
anything,  or  mildly  carbolized  vaseline  may  be  used.  A  pleas- 
ant preparation  is  made  of  cocoa  butter,  scented  with  almond 


304  THE  DISEASES  OF  CHILDREN. 

oil.  This  is  prepared  by  some  of  our  city  druggists  and  dis- 
pensed under  the  name  of  "  Unguentum  Grecorum." 

The  attending  physician  should  have  a  linen  duster  in  an 
adjoining  apartment  that  he  can  slip  on  before  entering  the 
sick  room  and  discard  after  leaving  it.  The  nurses  or  attend- 
ants should  not  mingle  with  the  well  members  of  the  family, 
until  desquamation  is  completed.  When  this  process  is  over, 
and  as  soon  as  the  attending  physician  deems  it  prudent,  the 
patient  should  be  given  a  bath  of  warm  water  and  soap,  followed 
by  a  brisk  rubbing  with  dilute  alcohol.  For  some  time  subse- 
quently, great  care  should  be  exercised  to  avoid  exposure,  for 
a  scarlet-fever  convalescent  is  wonderfully  susceptible  to  cold. 

As  soon  as  vacated,  the  sick  room  should  be  thoroughly  dis- 
infected by  the  burning  of  sulphur,  after  which  it  should  be  well 
aired,  the  walls  newly  calcimined  or  freshly  papered,  and  the 
woodwork  and  floors  scrubbed  with  carbolized  water  and  soap- 
suds. The  mattress  and  bed  linen,  as  well  as  the  body  clothing 
which  has  been  used  in  the  sick  room,  should  be  disinfected  or 
destroyed  by  burning.  The  use  of  disinfectants  about  the 
room  during  the  illness  is  of  questionable  utility. 

A  well-moistened  sheet  hung  in  the  doorway  is  useful  in 
preventing  the  poisonous  emanations  from  infecting  other 
portions  of  the  house.  Carbolic  acid  or  other  offensive  dis- 
infectants should  never  be  used.  Such  inodorous  prepara- 
tions as  Piatt's  chlorides  or  permanganate  of  potash  are  far 
preferable. 

As  to  the  value  of  belladonna  internally  administered  as  a 
prophylactic  in  this  disease,  there  is  some  divergence  of  opinion. 
The  great  weight  of  evidence,  however,  is  in  its  favor.  It  is 
neither  a  specific  in  all  forms  of  the  disease  as  a  curative  rem- 
edy, nor  can  it  always  be  depended  upon  as  a  reliable  preven- 
tive ;  but  there  is  unquestionable  and  ample  evidence  to  show 
that  when  it  does  not  prevent  an  attack  it  modifies  and  controls 
its  severity.  The  writer  always  administers  it  to  the  well 
members  of  the  family,  who  are  not  already  protected  by  a 
previous  attack  of  the  disease,  and  he  has  never  yet  seen  a 
severe  case  of  scarlet  fever  that  had  previously  taken  the 
remedy.  As  a  prophylactic,  belladonna  should  not  be  given 
lower  than  the  sixth  decimal  dilution,  probably  the  twelfth 
would  be  equally  efficacious.  But  belladonna  is  not  the  only 
remedy  which  has  been  used  and  highly  esteemed  by  many  for 
its  prophylactic  powers.  Dr.  Samuel  Lilienthal  says  in  the 
"Transactions of  the  American  Institute  of  Homeopathy  "  (vol. 
1880):  "  What  is  malignant  scarlet  fever?  It  may  be  answered 
in  two  words,  albuminuria  and  uremia;  that  peculiar  kind 
of  blood  poisoning  resulting  from  the  change  of  urea  into  the 


SCARLA  TINA ;  SCARLE  T  FE  VER.  305 

carbonate  of  ammonia  ;  and  carbonate  of  ammonia,  or  rather 
the  sesquicarbonate  of  ammonia,  has  been  for  ages  a  favorite  pre- 
scription in  zymotic  diseases,  with  physicians  of  the  old  school. 

"  My  friend,  Dr.  John  C.  Morgan,  of  Philadelphia,  acknowl- 
edged with  great  satisfaction,  that  his  success  in  the  treatment 
of  this  fearful  disease  arises  from  the  early  and  steady  employ- 
ment of  this  salt,  a  drug  perfectly  homeopathic  to  the  disease, 
and  thus  he  prevents  that  very  decomposition  of  the  blood 
which  is  the  cause  of  the  ammoniemia.  Look  at  the  symp- 
toms of  the  drug,  and  I  doubt  whether  in  our  whole  materia 
niedica  there  is  a  drug  whose  every  symptom  is  so  characteris- 
tic of  this  disease.  Strong  febrile  irritation,  red  diffused  spots, 
with  sensation  of  heat  and  subsequent  desquamation,  espe- 
cially of  the  trunk,  arms,  and  thighs ;  inflammatory  swelling  of 
tonsils,  and  of  the  sub-maxillary  glands ;  angina,  with  viscid 
phlegm ;  putrid  sore-throat  and  gangrene ;  feeling  of  great 
prostration  ;  catarrhal  condition  of  the  kidneys  and  bladder, 
with  scanty  and  painful  discharge ;  and  the  thought  must  im- 
press itself  upon  our  minds,  if  generalization  could  be  allowed 
in  our  school,  that  the  sesquicarbonate  of  ammonia  deserves 
far  more  to  be  used  as  a  preventive  than  the  so-much-vaunted 
belladonna." 

Treatment. — It  cannot  be  too  strongly  impressed  upon  the 
student  and  the  practitioner,  that  there  is  no  one  specific  for 
scarlatina.  A  disease  which  is  so  variable  in  its  manifestations ; 
so  eccentric  in  its  course ;  so  full  of  surprises,  even  in  its  mild- 
est form  cannot,  in  the  nature  of  things,  be  treated  successfully 
in  a  stereotyped  way.  In  fact  there  is  no  disease,  unless  it  be 
entero-colitis,  in  which  so  great  a  range  of  remedies  is  likely  to 
be  needed. 

The  value  of  belladonna  in  the  regular  form  of  the  disease, 
and  especially  when  the  eruption  is  smooth  and  the  angina  of 
mild  type,  is  very  great,  and  if  the  cerebral  symptoms  are  in 
correspondence  with  the  drug,  its  effect  is  marvelous.  But  in 
the  irregular  and  malignant  forms  of  the  disease,  there  are 
other  remedies  of  far  greater  merit.  Apis,  ailanthus,  arseni- 
cum,  gelsemium,  mercurius  and  terebinthina,  are  drugs  that 
will  frequently  be  called  for,  and  will  greatly  excel  belladonna, 
in  their  curative  effects.  In  the  first  onset  of  an  attack,  and  in 
the  absence  of  symptoms  calling  for  some  other  drug,  aconite 
and  belladonna  will  be  most  commonly  indicated.  In  severe 
cases,  especially  when  attended  with  great  prostration  and 
typhoid  tendencies,  rhus  tox.,  arsenicum,  veratrum  viride, 
ammonia  sesquiox.,  or  solanum,  may  be  required.  In  cases 
which  show  great  malignancy,  arsenicum,  lachesis,  ailanthus, 
and  camphor  are  to  be  remembered. 
D.  C— 20 


306  THE  DISEASES  OF  CHILDREN. 

Where  there  is  great  restlessness,  gelsemium  will  be  found 
of  value  ;  for  the  nocturnal  delirium,  hyoscyamus  or  passiflora. 
On  the  first  indications  of  dropsy,  apis  or  arsenicum  will  be 
needed.  The  choice  between  the  two  remedies  will  depend  on 
the  rapid  swelling  of  the  throat,  and  sharp  stinging  pains  in  the 
fauces ;  when  the  rash  is  interspersed  with  a  miliary  eruption, 
and  when  with  suppression  of  eruption  there  is  also  suppression 
of  urine,  all  of  which  symptoms  indicate  apis.  Arsenicum  is 
indicated  in  malignant  cases,  when  there  is  great  prostration  of 
the  vital  powers ;  when  there  is  great  thirst,  and  when  there  is 
a  fetid  discharge  from  the  nostrils  (ailanthus).* 

For  anasarca  and  threatened  hydrocephalus,  helleborus  nig. 
is  the  chief  remedy. 

But  the  reader  is  referred  to  the  following  list  of  remedies 
and  their  chief  indications,  a  careful  study  of  which  will  be 
sufficient  to  differentiate. 

Aconite. — Intense  restlessness;  very  irritable;  skin  very  hot, 
dry  and  congested  ;  face  expresses  fright  and  anguish ;  head- 
aches ;  intense  burning  thirst ;  in  stomach  in  later  periods,  sud- 
den violent,  burning,  shooting  pains ;  sweat  on  whichever  side 
patient  lies ;  severe  retching  with  vomiting  of  green  mucus^ 
mixed  with  bile  or  blood. 

Ailanthus. — Face  flushed  and  burning;  restless,  yet  at  the 
same  time  very  drowsy,  which  increases  to  insensibility,  with 
low,  muttering  delirium ;  severe  headache  with  photophobia ; 
eruption  of  a  miliary  rash,  of  a  livid  color,  the  intervening 
spaces  being  of  a  dull  opaque  appearance,  in  patches,  mostly  on 
face  and  neck ;  excessive  vomiting ;  tongue  dry  and  cracked  ; 
throat  dark  colored,  and  in  some  cases  glands  are  greatly  swol- 
len and  ulcerated  ;  skin  cold  and  dry ;  the  livid  color  returns 
very  slowly  when  pressed  out  by  the  finger. 

Ammonium  Carb. — In  malignant  cases  with  lethargic  condi- 
tions, threatened  gangrene  ;  eruption  developed  but  slightly, 
with  stupor,  sleepiness,  burning  pain  and  dryness  of  mouth ; 
burnmg  pam  in  throat,  which  is  sore  and  exhales  a  foul  odor ; 
parotids  and  lymphatics  of  neck,  especially  of  right  side,  hard 
and  swollen  ;  tonsils  enlarged  and  of  a  livid  color  and  covered 
with  a  foul  smelling  mucus  which  rapidly  degenerates ;  exces- 
sive vomiting,  accompanying  threatened  paralysis  of  the  brain  ; 
head  heavy;  breathing  stertorous;  stools  passed  involuntarily. 

Apis. — Unconsciousness,  delirium,  convulsions,  sopor  with 
piercing  shrieks,  cerebral  irritation,  gnashes  the  teeth,  shrieks, 
rolls  the  head  ;  accelerated  and  oppressed  breathing  ;  pulse  slow 
and  irregular ;  skin  changes  from  hot  to  cold,  or  one  part  hot 

•Bryonia  will  be  found  very  effective  in  cases  where  the  exanthem  is  slow  in  appearing 
or  appe'aring  irregularly.  * 


SCARLA  TINA ;  SCARLE T  FE  VER.  307 

and  another  cold  ;  discharge  of  thick,  white,  bloody,  fetid  mucus 
from  the  nose ;  great  trembling  of  the  limbs ;  gradual  and  con- 
stant increase  of  fever,  with  frequent  changes  in  character  of 
pulse  ;  swallowing  difficult  from  swollen  tonsils ;  urine  scanty 
and  high  colored,  passed  frequently  and  with  stinging  pains; 
entire  abdomen  sensitive  to  touch  ;  slimy  and  bloody  diarrhea ; 
during  desquamation  symptoms  of  dropsy.  According  to  Wolf, 
where  the  virus  thoroughly  poisons  the  blood,  the  whole  ner- 
vous system  is  under  its  paralyzing  influence  ;  the  fever  becomes 
typhoid  in  character,  the  tongue  deep  red  and  covered  with 
blisters,  which  become  converted  into  stinging  sores  and  ulcers. 

"  Never  useful  in  coryza  form,  only  with  dryness  of  nose  and 
throat  and  symptoms  of  hydrocephalus." — Hering. 

According  to  O.  P.  Baer,  the  indications  for  apis  are,  "  skin 
unevenly  scarlet  and  rough,  by  being  covered  with  hard,  sharp, 
pointed  rash."  In  this  form  of  the  disease,  he  says  it  is  as  com- 
pletely curative  as  is  belladonna  where  the  skin  is  evenly  scarlet 
all  over,  smooth  and  shining. 

Apocynum.  Cannabinum. — Mind  bewildered ;  great  thirst,  but 
water  rejected  soon  as  taken  ;  abdomen  distended  and  painful ; 
scanty  urine  with  no  uneasiness  in  consequence ;  profuse  light- 
colored  urine  with  no  sediment ;  general  restlessness  with  debil- 
ity ;  excretions  generally  diminished,  especially  urine  and 
sweat. 

Arnica. — In  typhoid  conditions,  with  nose-bleed  and  bloody 
expectoration  aggravated  by  coughing  ;  ecchymoses  on  various 
portions  of  the  body,  or  even  small  boils. 

Argentum  Nit. — Eruption  dark,  bluish,  or  even  black,  accom- 
panied by  convulsions  ;  convulsions  preceded  by  extreme  rest- 
lessness and  tossing  about ;  passage  of  quantities  of  greenish 
mucus,  with  copious  emission  of  foul-smelling  flatus. 

Arsenicum. — In  malignant  cases,  eruption  delayed,  or  sud- 
denly turns  pale  or  livid,  surrounded  by  petechie ;  drinks  fre- 
quently,  but  little  at  a  time  ;  extremely  restless  and  anxious ; 
prostration,  mild  delirium ;  spasmodic  action  of  tendons, 
with  violent  vomiting;  eating  or  drinking  brings  on  violent 
diarrhea ;  lips  dark  or  black,  cracked  and  often  bleeding ; 
grinds  teeth  during  sleep  ;  eating  leaves  a  bitter  taste  in  mouth  ; 
great  desire  for  acids  and  cold  drinks ;  vomiting  of  blood  and 
mucus  ;  hematuria  ;  urine  scalding,  nd  voided  with  difficulty  ; 
edema  of  eyelids  ;  cold  perspiration  and  extremities  ;  tendency 
to  dropsy  ;  must  constantly  move  and  change  position  on  ac- 
count of  oppression  of  breath  ;  great  emaciation  ;  albuminuria. 

Arum  Triph. — Upper  lip  and  nostrils  excoriated  by  sanious 
discharge  from  nose ;  mouth,  fauces,  and  posterior  nares 
sore  ;  nose  and  lips  bleed  from  constant  picking  ;  ulcerous  sore 


808  THE  DISEASES  OF  CHILDREN. 

throat ;  feeling  of  burning  in  larynx  and  fauces,  with  moist 
cough  during  day,  but  at  night  is  compelled  to  sit  up  from 
spasmodic  cough  ;  nose  obstructed,  with  or  without  a  thick, 
yellow  discharge  which  fills  the  throat  and  nasal  cavity  ;  ulcers 
in  mouth,  with  burning  pain  and  soreness  ;  tongue  raw,  sore 
and  papille  elevated ;  saliva  hot  and  burning;  swelling  of  left 
submaxilliary  glands  ;  neck  becomes  stiff ;  itching  of  eruption 
which  is  spread  over  the  whole  body  ;  urine  copious  and  high- 
colored  ;  high  fever. 

Asclepias  Syr. — For  dropsy  of  post-scarlatinal  nephritis. 

Aurum  Met. — Nose  when  touched  feels  sore;  discharge  of 
offensive  mucus  from  nose  ;  extremely  fetid  otorrhea ;  caries, 
with  passage  of  small  fragments  of  bone  from  the  ear ;  condi- 
tions analogous  to  mercurial  or  scrofulous  disease,  with  ten- 
dency to  destruction  of  tissue  in  the  parts  affected ;  bone  affec- 
tions ;  painful  swelling  of  submaxillary  glands ;  mind  peevish 
and  irritable  ;  least  thing  excites  anger. 

Baptisia. — Mind  wanders,  and  feels  as  if  portions  of  body 
were  here  and  there ;  face  hot  and  dark-red ;  tongue  at  first 
dry  and  sore,  with  a  white  coating,  and  red,  elevated  papille, 
which  later  changes  to  a  yellowish-brown  in  center,  and  dry, 
shining  dark-red  on  edges  ;  diphtheritic  ulcers  in  throat ;  tonsils 
inflamed  and  swollen  ;  foul-smelling  breath ;  great  dyspnea ; 
urine  scanty,  dark-colored  and  burning ;  bloody  stools  with 
tenesmus ;  typhoid  conditions ;  fever  continues,  accompanied 
by  great  weakness  and  loss  of  strength. 

Baryta  Carb. — During  and  after  desquamation. — Raue.  Sub- 
maxillary glands,  tonsils  and  parotids  swollen  and  painful; 
much  saliva  in  mouth  or  is  very  dry ;  violent  pains  and  spas- 
modic contractions  in  tonsils  and  fauces  on  swallowing. 

Belladonna. — Delirium,  accompanying  congestion  of  brain; 
when  asleep,  starts  up  suddenly,  dreams,  is  anxious,  or  tries  to 
get  up  and  walk ;  feels  sleepy,  but  cannot  sleep ;  on  closing 
eyes,  sees  frightful  objects;  carotids  throb  violently  ;  head  hot- 
ter than  body ;  head  bent  backwards ;  moves  hand  to  head 
involuntarily ;  swallowing  painful  and  diflficult,  especially  fluids, 
which  sometimes  return  through  the  nose ;  nausea  and  vomit- 
ing ;  often  dreads  water,  but  has  violent  thirst ;  glands  of  neck 
swollen ;  injection  of  the  eyes;  fiery  red  face,  or  sunken,  or  is 
pale  and  puffed;  tongue  coated  white  and  edges  red 

"  Belladonna  is  only  indicated  in  the  smooth  form  of  eruption, 
with  vascular  and  nervous  excitement ;  it  does  no  good  in  ady- 
namic cases.  The  miliary  form  of  eruption  is  much  more 
adapted  to  amm.  carb. ;  lachesis.,  or  rhus.  tox." — Raue. 

Bryonia. — Face  red  and  hot ;  lips  dry  and  cracked ;  while 
asleep  does  not  completely  close  eyes ;  tongue  dry  and  thickly 


SCARLA  TINA ;  SCARLET  FB  VER.  309 

coated  brownish- white ;  large  quantities  of  alkaline,  frothy 
saliva ;  sudden  disappearance  or  delay  of  eruption,  causing 
dropsy,  pleuritis  or  meningitis;  motion  aggravates  all  symp- 
toms, while  quiet  ameliorates  ;  obstinate  constipation  ;  slightest 
motion  brings  on  nausea  and  vomiting;  excessive  thirst  for 
large  quantity  of  water,  which  is  retained,  while  solids  are 
immediately  vomited. 

Eruption  does  not  appear  after  third  day;  face  is  pale  and 
puffed  up ;  throat  greatly  inflamed,  aphthous  condition  of  roof 
of  mouth  and  tonsils;  breathing  anxious  and  oppressed  with 
tendency  to  paralysis  of  lungs ;  glands  of  neck  become  hard 
and  swollen  ;  nose  ulcerated  and  stopped  up  ;  no  cough ;  breath 
very  hot ;  "  otorrhea  a  sequela." 

Capsicum. — Throat  burning  and  painful,  worse  between  swal- 
lows ;  tongue  dry  and  covered  with  burning  vesicles ;  redness 
and  burning  of  face,  heat  of  face  greater  than  body;  throat  and 
mouth  burn  and  are  of  a  deep-red  color;  tough,  sticky  mucus  in 
mouth  and  throat,  difficult  to  remove ;  variable  humor ;  vomit- 
ing of  phlegm  ;  no  thirst ;  excitability  of  all  the  senses. 

Carbolic  Acid. — Tongue,  which  at  first  is  coated  white,  clears 
up  and  is  glossy  and  red ;  foul  odor  of  breath  ;  fauces  bright- 
red  and  swollen ;  breathing  and  swallowing  are  difficult  from 
throat  being  swollen  both  inside  and  outside ;  face  a  dark-red 
color,  while  around  mouth  is  a  white  circle :  nose  obstructed  ; 
dryness  and  chapping  of  lips ;  slight  tympanites  of  abdomen ; 
urine  scanty  and  very  dark ;  mucus  exudation  in  patches  on 
tonsils  and  pharynx ;  body  covered  with  a  scurfy  eruption ; 
frequent  diarrheic,  foul-smelling  discharges. 

Coffea  Cruda. —  Special  senses  very  acute;  intense  mental 
and  physical  excitement  causes  sleeplessness ;  body  hot  to 
touch,  but  patient  chilly ;  palpitation  of  the  heart. 

Colchicum.  —  Exceedingly  irritable,  with  an  expression  of 
suffering  on  the  face;  tongue  swollen  and  thickly  coated  white; 
mouth  inflamed,  with  profuse  saliva;  smell  of  food  irritates 
him,  brings  on  vomiting ;  stools  slimy,  foul-smelling  and  exceed- 
ingly painful ;  urine  dark,  like  ink,  scanty  and  passed  with  diffi- 
culty and  very  painful,  burning  sensation  ;  albuminurea ;  dropsy. 

Coniutn  Mac. — Delirium ;  loss  of  consciousness  ;  headache 
worse  in  morning  ;  burning,  shooting  pain  in  lips  ;  difficulty  of 
speech  from  paralysis  of  tongue  ;  salivary  glands  swollen  and 
hard  ;  vomiting  of  dark-colored  masses,  like  coffee  grounds, 
very  acrid  ;  frequent  urination,  with  burning  during  and  after  ; 
black  deposits  on  lips  ;  skin  very  hot. 

Cuprum  Met. — Delirium  with  mutterings  and  fragmentary 
speech  ;  sopor ;  constant  uneasiness  and  tossing  about ;  convul- 
sions from  sudden  recession  of  eruption  ;  contractions  of  flexor 


310  THE  DISEASES  OF  CHILDREN. 

muscles,  and  also  of  facial  muscles,  causing  distortions  of  face. 
"  Clings  tightly  to  nurse,  but  is  afraid  of  everybody  else  ;  fears 
of  falling,  or  that  fire  will  destroy  the  bed-clothes  ;  wants  to 
stay  in  nurse's  lap  ;  eruption  does  not  appear,  which  causes 
terribly  sore  throat." — Gardiner. 

Digitalis.  —  Especially  useful  in  post-scarlatinal  nephritis, 
with  the  following  indications :  great  anxiety,  feels  as  though 
he  were  dying;  vertigo;  throbbing  pain  in  forehead;  violent 
thirst,  with  extreme  nausea  and  vomiting:  stools  colorless, 
nearly  white  ;  urine  scanty,  dark-colored,  passed  frequently, 
with  burning  and  Httle  at  a  time  ;  edema  of  lungs ;  extremely 
slow,  small,  weak  pulse. 

Gelsemium. — Apathy,  wants  to  be  let  alone,  no  desire  to 
play  or  be  amused ;  frequent,  copious  discharge  of  pale  urine, 
which  slightly  relieves  dull,  aching  pain  in  head  ;  tongue  coated 
thickly  white  •,  eruption  slightly  developed  ;  face  dull  and  heavy- 
looking;  thickness  of  speech;  intense  nervous  excitement  or 
drowsiness  and  languor  ;  tonsils  swollen  and  injected.  "  Hands 
and  feet  cold  ;  eyes  suffused  and  heavy-looking  ;  all  the  viscera 
are  threatened  when  the  eruption  recedes ;  in  all  positions  the 
whole  face  is  a  high  crimson  ;  delirious  mutterings  while  asleep 
or  half  awake ;  sensation  in  throat  as  if  it  were  filled  up  ;  lan- 
guor and  drowsiness  with  heat." — Morgan. 

Helleborus. —  Head  feels  dull  and  heavy,  with  stupor  and  uncon- 
sciousness; photophobia  with  dilated  pupils;  face  colorless  and 
edematous  ;  vomiting  of  dark  greenish  masses  ;  painful  mucoid 
stools,  like  thick  albumin ;  urine  scanty,  frequent  micturition, 
deposits  sediment  like  coffee  grounds ;  post-scarlatinal  dropsy. 
This  drug  is  very  useful  when  the  mental  condition,  viz.,  semi- 
consciousness approaching  coma,  is  united  with  suppression  of 
urine  more  or  less  marked. 

Hyoscyamus. — Arouses  from  stupor  to  answer  questions,  but 
immediately  relapses  into  former  condition  ;  muscles  twitch  and 
jerk  here  and  there  over  the  body ;  extreme  sleeplessness  and 
nervous  excitability ;  illusions  crowd  upon  the  mind  ;  eyes  red 
and  shining,  with  staring,  stupid  look  ;  inability  to  swallow,  with 
dryness  and  redness  of  mouth  and  throat ;  water}',  painless 
diarrhea,  passed  involuntarily  in  bed ;  urine  scanty  and  passed 
with  difficulty  or  involuntarily. 

lodium. — Great  emaciation  ;  face  pale  or  with  a  bluish-green 
cast ;  blue  haze  before  the  eyes ;  glands  of  neck  and  throat 
swollen  and  ulcerated  :  great  appetite,  but  vomits  as  soon  as  he 
eats ;  all  symptoms  aggravated  by  warmth. 

Ipecacuanha. — Vomiting  of  greenish  mucus  and  bile ;  diar- 
rhea of  green  mucus  mixed  with  blood ;  intense  itching 
after  suppression  of  the  eruption  ;  moans  and  keeps  eyes  half 


5  CA  RLA  TINA  ;  S  CA  RLE  T  FE  VER.  311 

open  during  sleep ;  difficult,  sighing  respiration ;  cough  and 
vomiting. 

Kali-bichroniicuni.  —  Violent  stitches  in  left  ear  extending 
from  throat  when  swallowing ;  discharge  of  blood-streaked, 
tenacious,  excoriating  mucus  from  nose ;  throat  dark,  livid  and 
covered  with  diphtheritic  exudation  ;  parotids  swollen  and  pain- 
ful ;  tongue  ulcerated,  smooth  and  red ;  ulcers  on  fauces  ;  pu- 
rulent infiltration  of  mucous  membrane  of  nose  and  throat ; 
furfuraceous  eruption. 

Kali  carb.  —  Eyelids  swollen,  and  hang  down  like  sacs ; 
mouth  dry,  covered  with  burning  vesicles,  and  exhaling  an 
odor  like  old  cheese  ;  parotids  swollen  and  inflamed  ;  burning, 
dry  feeling  of  skin  ;  very  restless,  with  high  fever. 

Lachesis. — Delirium  with  constant  mutteringsand  constantly 
changing  moods  ;  dull,  heavy  headache,  with  deep-seated  pains 
in  brain  ;  discharge  from  nose  watery,  bloody,  thick  and  dark ; 
crusts  form  in  nose ;  tongue  swollen,  and  so  heavy  cannot  pro- 
trude it  beyond  the  lower  teeth  ;  difficult  speech ;  tongue  cov- 
ered with  blisters,  black,  stiff  and  cracked ;  throat  so  sensitive 
cannot  bear  the  slightest  weight  on  it,  glands  swollen  and  sup- 
purating :  cannot  swallow  fluids,  they  return  through  the  nose ; 
diphtheritic  deposit  first  on  left  side,  then  gradually  extends 
over  the  whole  throat ;  offensive,  sudden,  watery  stools ;  fre- 
quent urgings  to  pass  foaming,  dark,  copious  urine ;  eruption 
becomes  bluish  or  black,  with  great  dyspnea ;  effusion  into 
the  pleura  and  pericardium,  also  general  dropsical  condition  ;  in 
malignant  cases,  with  sloughing  ulcers,  or  which  become  gan- 
grenous and  discharges  are  foul  and  acrid  ;  in  typhoid  states. 
A  marked  characteristic  indication  for  lachesis  is  aggravation  of 
all  the  symptoms  after  sleep. 

Lachnanthcs. — Eyes  brilliant  and  sparkling  ;  much  thirst,  with 
burning  in  head  like  fire  ;  redness  of  face  in  circumscribed  spots  ; 
throat  sore  and  dry  with  sticking  pains  on  swallowing;  when 
eruption  about  to  appear,  there  is  a  sensation  of  heat  and  burn- 
ing on  the  surface. 

Lycopodhun. — Dull,  peevish,  fretful ;  discharge  from  ear  pu- 
rulent ;  hair  falls  out  ;  patches  on  right  tonsil  extending  to  left; 
face,  hands  and  feet  swollen  and  puffy;  nose  stuffed  up,  with 
acrid  discharge  from  right  nostril ;  submaxillary  and  glands  of 
neck  swollen,  hard,  and  very  sensitive  ;  urine  passed  frequently 
in  small  quantities,  and  with  burning  ;  urine  milky,  scanty,  de- 
posits sand-like  sediment  ;  constipation  and  colicky  pains  dur- 
ing desquamation. 

"  Secondary  eruption  of  dark-red  blotches  on  thighs,  back, 
and  face." — Raue. 

Mercurius. — Ears  inflamed,  sore  and  excoriated   from  dis- 


312  THE  DISEASES  OF  CHILDREN. 

charge  which  is  bloody  and  offensive ;  grayish,  dirty  yellow 
coating  on  tongue  ;  impression  of  teeth  on  edges  of  tongue  ; 
mouth  sore  and  covered  with  vesicles ;  salivation  ;  glands  of 
neck  and  tonsils  swollen  and  suppurating  ;  itching  all  over  the 
body  aggravated  by  the  warmth  of  the  bed  or  perspiration  ; 
foul-smelling  breath  ;  exceedingly  painful  swelling  of  bones  of 
nose. 

Mercurius  lod.  Flav. — Swelling  and  long-standing  indurations 
of  glands  of  neck,  tonsils  and  parotids ;  tongue  covered  with  a 
thick,  dirty-yellow  coating,  edges  red  and  clean ;  pain  in  left 
ear  which  is  deep-seated  and  throbbing,  and  boring  in  charac- 
ter; infiltration  of  throat  and  neck;  discharge  of  very  greenish 
mucus  from  throat  and  nares  ;  after  lachesis  for  hoarseness ; 
dark,  scanty  urine. 

Muriatic  Acid. — Mouth  and  throat  very  dry,  ulcerated  and 
foul  odor  ;  entire  face  red,  body  very  hot  and  skin  purple ;  up- 
per lip  and  nostrils  excoriated  by  acrid  discharge  from  nose; 
fauces  dark  red,  and  covered  with  aphthae  ;  coma  at  beginning 
of  attack,  with  rapidly  spreading,  intense  redness  ;  rapid,  small, 
very  weak  pulse  ;  in  typhoid  conditions,  patient  sinks  away 
down  in  bed ;  eruption  is  interspersed  with  petechiae ;  patient 
so  anxious  and  restless  that  he  cannot  keep  the  covers  on  ;  very 
deep,  groaning,  audible  respirations. 

Nitric  Acid. — Mouth  and  throat  very  dry  and  burning,  cov- 
ered with  deposits  resembling  diphtheria  ;  tongue  swollen,  dry, 
and  cracked,  hindering  speech  and  swallowing  ;  offensive,  thin, 
purulent  discharge  from  nose  and  ears ;  skin  covered  with  a 
fine  miliary  eruption  and  burning  hot ;  parotids  and  submax- 
illary glands  swollen,  with  deafness.  "All  secretions  and  excre- 
tions exceedingly  fetid  smelling  ;  gums  dark  red,  swollen,  and 
easily  bleeding,  with  foul  odor  from  mouth  ;  no  swelling  of 
fauces,  but  are  darker  in  color  ;  vomiting  ;  exhausting  epistaxis 
of  dark-red  blood." — Kunkel. 

Opium.  —  Eyes  wide  open,  stupid,  easily  frightened,  sees 
frightful  images ;  delirious  and  unconscious,  with  slow,  ster- 
torous breathing ;  paralysis  of  throat,  with  dryness  and  inability 
to  swallow ;  symptoms  of  cerebral  oppression  with  heavy 
breathing ;  retention  of  scanty,  dark-brown  urine ;  picks  at 
bed-clothes  ;  cannot  stay  in  bed  because  it  is  too  hot. 

Phosphorus. — Unconsciousness,  with  low,  muttering  delirium  ; 
congestion  of  head  ;  pupils  contracted  ;  fluent  coryza ;  falling 
out  of  the  hair ;  tongue  dry,  cracked,  swollen,  brown  coating, 
and  immovable  ;  eyes  and  lids  swollen  ;  deafness,  especially  to  the 
human  voice  ;  thirst,  drinks  large  quantities  of  very  cold  liquids ; 
alarming  rattling  in  throat ;  suspicious  chest  symptoms  accom- 
panying disappearance  of  eruption  ;  uneasiness  and  restlessness 


SCARLATINA;  SCARLET  FEVER.  313 

from  a  sensation  of  burning ;  pulse  exceedingly  rapid,  small 
and  weak ;  urine  scanty,  dark-brown  and  deposits  a  red  sandy 
sediment ;  diarrhea  ;  ecchymoses. 

Phosphoric  Acid. — Pulse  irregular,  frequent,  small,  weak, 
sometimes  palpitation  ;  throat,  mouth  and  tongue  dry,  without 
thirst  ;  involuntary  diarrhea,  stools  thin,  watery,  yellowish  and 
painless ;  epistaxis  of  dark-red  blood  ;  quiet,  indifferent,  stupid, 
even  to  imbecility,  aversion  to  speaking,  cannot  answer  cor- 
rectly, uses  wrong  words  ;  rumbling  and  gurgling  in,  and  dis- 
tension of,  abdomen ;  bed-sores  of  a  bluish-red  color ;  profuse 
sticky  perspiration  during  night. 

PJiytolacca. — Throat  and  fauces  dry,  sore  and  congested  ;  sen- 
sation of  a  lump  in  throat  when  swallowing,  also  violent  pain 
extending  to  both  ears ;  tonsils  swollen,  and  covered  with 
patches  resembling  diphtheria  ;  pains  in  arms  and  legs  like 
rheumatism  ;  very  restless  and  sleepless,  while  hands  and  feet 
are  so  hot,  cannot  keep  them  covered  ;  skin  is  dry  and  harsh  and 
feels  like  rough  paper;  eruption  dry  and  shriveled  ;  urine  sup- 
pressed, with  violent  pains  in  head,  back,  and  lower  limbs. 

Podophyllum.  —  "  Distressing  nausea  ;  intense,  long  lasting 
vomiting  of  dark-green,  watery  mucus  ;  useful  to  control  vomit- 
ing when  other  remedies  fail." — Richardson: 

Rhus  Tox. — Impatient,  restless,  low  delirium,  with  stupor ; 
putrid  sore  throat,  first  on  left  side,  then  on  right ;  parotids  and 
submaxillary  glands  swollen  and  discharging  copiously  ichorous 
pus  ;  excoriating  discharge  from  nose  ;  nightly  epistaxis  ;  tongue 
dry,  cracked,  and  red  on  edges ;  eruption  dark  red  and  livid, 
with  intense  itching  over  whole  body ;  eruption  of  fine  vesicles 
which  burn  and  itch ;  mouth  and  throat  very  dry,  causing 
intense  thirst  for  cold  drinks  ;  penis  and  scrotum  swollen. 

Secale. — Raving  delirium,  with  tendency  to  bite  those  near 
him  ;  fears  dying ;  deep,  sighing  respiration  ;  dry,  brown  or 
blackish  tongue,  with  constant  unquenchable  thirst ;  rapid  loss 
of  strength,  with  trembling  of  the  whole  body,  and  great  rest- 
lessness ;  nose  feels  stopped  up,  yet  there  is  a  profuse  watery 
discharge ;  cannot  remain  covered  or  bear  the  least  warmth ; 
involuntary,  very  offensive,  slimy  stools,  with  scanty  discharges 
of  bloody  albuminous  urine. 

Silicia. — Drawing  and  stitching  pains,  with  roaring  in  ears, 
when  swallowing ;  ears  so  painful  that  patient  puts  her  hands 
behind  them  ;  in  scrofulous  patients,  glands  swell  and  suppu- 
rate ;  suppuration  of  parotid,  which  is  very  much  enlarged  ; 
otitis  media  and  caries  of  mastoid  processes  ;  very  sensitive  to 
cold,  takes  cold  easily,  desires  to  be  warm  and  well  covered  up; 
boils  and  abscesses  come  in  series. 

Stramonium. — Delirium,  variable  mood  ;  eyes  sore  and  pain- 


314  THE  DISEASES  OF  CHTLDREN. 

ful,  pupils  dilated,  photophobia  so  intense,  that  light  causes 
convulsions ;  tongue  yellowish-brown,  swollen,  stiff  and  dry ; 
speech  difficult  or  unintelligible  from  paralysis  of  tongue ; 
mouth  and  throat  very  dry,  with  violent  thirst,  especially  for 
acids;  nausea  and  vomiting;  restlessness,  with  violent  trem- 
blings over  whole  body  ;  urine  suppressed,  and  stools  are  passed 
involuntarily,  and  are  of  decomposing,  foul-smelling  blood  ;  skin 
dry  and  hot,  rash  very  fine,  dark  red  and  with  intense  itching. 

Sulphur. — Nose  feels  sore,  dry,  stopped  up,  with  fluent 
excoriating  discharge  ;  face  swollen,  dark  red  and  burning,  with 
distorted  appearance  of  eyes ;  tongue  coated  white,  red  edges 
and  covered  with  brownish  mucus ;  eruption  turns  from  a 
bright  red  to  dark  purple,  followed  by  diarrhea,  worse  in  the 
early  mornings ;  white  circle  around  mouth ;  mouth  and  throat 
very  dry,  swallowing  difficult,  great  thirst ;  during  stage  of 
desquamation,  and  in  scrofulous  children. 

"  In  cerebral  affections  that  do  not  yield  to  bell." — Snelling. 

Terebinthina. — Unconsciousness,  with  intense  cerebral  con- 
gestion ;  violent  headaches,  relieved  by  passing  large  quantities 
of  smoky  urine ;  tongue  smooth,  bright  red  and  shiny ;  great 
thirst,  but  drinking  brings  on  nausea  and  vomiting;  vomiting 
and  diarrhea  of  yellow  mucus  and  water ;  urine  scanty,  pro- 
fuse, bloody,  albuminous,  and  intensely  hot ;  eruption  appears 
very  slowly,  with  burning  and  tearing  pains  in  kidneys ;  pulse 
small,  thready,  and  almost  uncountable ;  edema  of  upper  por- 
tion of  body. 

"Albuminuria  and  dropsy  after  scarlet  fever;  urine  greenish 
and  loaded  with  albumin;  much  thirst,  drinking  of  ten,  but  little 
at  a  time."— y.  B.  Bell. 

Veratrum  Viride. — Delirium,  with  mutterings,  dilated  pupils, 
incessant  headache,  nausea  and  vomiting,  and  sleeplessness; 
urine  dark,  cloudy  and  bad  odor;  tremblings,  twitchings  and 
contortions  of  muscles ;  great  prostration ;  red  streak  through 
the  middle  of  yellow  coating  on  tongue ;  great  arterial  excite- 
ment, active  congestions  and  intense  fever ;  eruption  preceded 
by  convulsions,  slow,  difficult  respirations  and  small,  quick, 
irregular  pulse  ;  rheumatism  and  edema. 

Zincum.  —  Respirations  short  and  quick,  panting;  stupor, 
preceded  by  convulsions ;  tendency  to  brain  paralysis ;  back  of 
head  and  neck  very  hot  and  covered  with  perspiration  ;  twitch- 
ings and  jerking  of  single  muscles  or  even  the  whole  body; 
forehead  and  face  cold,  pale,  distorted  and  covered  with  cold 
perspiration ;  child  is  unconscious,  perfectly  motionless  ;  body 
and  extremities  cold,  pulse  small,  quick  and  thready,  skin  pur- 
plish ;  stools  and  urine  passed  involuntarily  ;  urine  scant,  bloody 
and  hot ;  grates  the  teeth,  and  every  now  and  then  emits  fright- 


SCARLATINA;  SCARLET  FEVER.  315 

ful  screams ;  eruption  recedes ;  mouth  and  throat  very  dry, 
with  large  quantities  of  mucus  in  pharynx. 

For  suppression  of  urine,  with  or  without  dropsy,  there  is  a 
new  remedy  of  great  value,  known  as  Diuretin,  which  has 
within  the  last  two  years  served  us  when  other  and  better- 
known  drugs  had  utterly  failed.  It  is  obtained  in  the  form  of 
a  white  powder,  is  practically  tasteless  and  does  not  affect  the 
stomach  or  bowels,  even  when  given  in  large  doses.  It  may  be 
given  dissolved  in  water,  milk  or  any  other  desirable  medium. 
It  should  be  given  to  a  child  of  two  or  three  years  of  age,  in 
doses  of  two  to  three  grains,  repeated  every  three  hours,  until 
its  specific  action  on  the  kidneys  is  secured. 

In  some  cases,  its  effect  is  not  perceptible  until  seventy-five 
or  one  hundred  grains  have  been  taken.  In  one  case  of  post- 
scarlatinal dropsy,  to  which  we  were  called  in  consultation,  by 
Dr.  S.  P.  Hedges — the  child,  who  was  some  five  years  of  age, 
took  upwards  of  two  hundred  grains  in  the  course  of  three 
days,  before  its  full  action  was  manifested,  after  which  the  kid- 
neys performed  their  function  without  further  trouble. 

This  drug  will  rarely  be  needed,  if  other  well-verified  reme- 
dies are  sufficiently  studied  to  be  properly  affiliated. 

HYGIENIC  MANAGEMENT. 

Much  of  what  might  come  under  this  head,  has  already  been 
said  when  speaking  of  prophylaxis. 

The  sick  room  should  be  a  quiet  one,  and  as  far  as  possible 
removed  from  the  ordinary  living  rooms  of  the  family.  This 
is  essential,  not  only  to  prevent  the  spread  of  the  contagion, 
but  also  for  the  comfort  of  the  patient.  It  should  be  an  ample 
apartment,  well  ventilated,  and  kept  at  a  temperature  of  from 
65°  to  70°  Fahr.  The  strictest  cleanliness  should  be  maintained 
throughout  the  course  of  the  disease. 

All  handkerchiefs  and  discarded  linen  should  be  burned  or 
disinfected  before  being  used  again. 

The  evacuations  from  bowels  and  bladder  should  be  received 
into  vessels  charged  with  inodorous  disinfectants,  and  as  soon  as 
voided  should  be  immediately  disposed  of.  The  diet  should  be 
mainly  liquids,  and  consist  largely  of  milk,  koumiss  and  animal 
or  vegetable  broths.  Distilled  water  may  be  given  freely.  Ice 
may  be  held  in  the  mouth  until  dissolved,  and  will  be  very 
grateful  in  the  height  of  the  fever.  Where  prostration  threat- 
ens, it  may  be  combated  with  dilute  whisky  or  brandy.  In 
cases  where  the  stomach  is  intolerant  of  food,  the  strength 
may  be  supported  and  time  gained  by  the  use  of  nutritive  ene- 
mata.     For  this  purpose  we  have  had  great  satisfaction  in  the 


316  THE  DISEASES  OF  CHILDREN. 

use  of  "Murdock's  Liquid  Food,"  diluted  one-half  with  warm 
water. 

When  diphtheria  complicates  the  case,  the  remedies  and 
measures  should  be  employed  which  are  fully  described  when 
speaking  of  this  disease. 

The  use  of  peroxide  of  hydrogen  is  so  essential  in  such  cases, 
that  we  make  reiterated  mention  of  it  here.  In  cases  where 
the  eruption  is  dilatory  in  appearing,  and  the  skin  dry  and  hot, 
the  wet  sheet  pack  may  be  resorted  to  without  hesitation. 

In  the  early  part  of  the  disease,  when  the  temperature  runs 
up  to  or  exceeds  104°  Fahr.,  the  body  should  be  sponged  off 
frequently  with  cool  or  tepid  water. 

During  the  eruptive  stage  the  itching  of  the  skin  is  some- 
times very  annoying.  This  can  be  greatly  alleviated  by  rub- 
bing the  surface  over  frequently  with  olive  oil,  or  the  unguen- 
tum  grecorum,  previously  spoken  of.  When  the  kidneys  are 
involved,  hot  poultices  of  linseed  meal  should  be  placed  over 
the  loins,  and  changed  as  often  as  they  get  cold. 

In  anasarca,  the  hot  wet-sheet  pack,  by  opening  the  pores 
and  producing  a  derivative  action,  will  be  found  exceedingly 
serviceable.  Several  packs  may  be  given  in  the  course  of 
twenty-four  hours,  if  necessary,  and  the  patient  may  remain  in 
the  pack  for  one  or  two  hours  at  a  time. 

During  convalesence,  great  care  must  be  taken  to  avoid  ex- 
posure to  cold  ;  the  clothing  should  be  warm,  and  when  des- 
quamation is  fully  over,  the  patient  should  be  well  bathed, 
newly  clad,  and  only  allowed  to  exercise  moderately  until 
health  and  strength  are  fully  restored. 


CHAPTER   V. 

ROSEOLA. 

Definition. — The  term  roseola,  or  rose  rash,  is  used  so  differ- 
ently by  different  authors,  that  it  is  somewhat  puzzling  to  one 
who  seeks  for  a  plain  and  distinctive  definition  of  the  word.  It 
is  so  trifling  an  affection  that  some  authorities  ignore  it 
entirely,  while  others  only  refer  to  it  when  differentiating 
other  diseases  attended  by  an  efflorescence.  It  so  closely  sim- 
ulates certain  other  eruptive  fevers,  however,  notably  scarlatina, 
that  it  should  always  be  borne  in  mind  when  the  diagnosis  of 
this  latter  disease  is  in  doubt.  It  is  essentially  an  erythema  of 
reflex  origin,  and  usually  is  due  to  some  trifling  derangement 
of  the  stomach. 

Some  children  are  very  subject  to  it.  It  is  non-contagious, 
and  its  duration  is  seldom  longer  than  twenty-four  or  forty- 
eight  hours.  More  often  it  lasts  but  a  few  hours.  It  is  espe- 
cially common  in  spring  and  autumn,  and  this  partiality  to 
certain  seasons  of  the  year  has  given  rise  to  the  names,  "  roseola 
estiva  "  and  "  roseola autumnalis."  One  attack  does  not  prevent 
its  recurrence  ;  indeed,  a  child  who  has  once  had  it  is  very  liable 
under  similar  provocation,  to  have  it  again.  It  seems  to  be  more 
prevalent  in  some  families  than  in  others.  I  have  one  family  on 
my  regular  list  in  which  there  are  now  six  children.  Three  of  these 
children  have  had  one  or  more  attacks  of  roseola,  the  first  one 
being  attended  by  so  much  fever  and  redness  of  the  fauces  that 
I  was  quite  sure  it  would  prove  to  be  a  case  of  scarlet  fever.  I 
gave,  however,  a  qualified  diagnosis,  and  the  next  day  the  prepa- 
rations which  were  begun  to  isolate  and  care  for  scarlatina,  were 
abandoned,  as  my  patient  was  as  well  as  ever.  In  this  case  there 
was  not  only  the  deep  scarlet  rash  pervading  the  entire  body, 
and  a  sore  throat,  but  also  vomiting  and  a  temperature,  at  the 
time  of  my  visit,  of  104°  Fahr.  Such  a  case  as  this  is  very  con- 
fusing, and  emphasizes  the  fact  that  in  all  of  these  eruptive  dis- 
eases the  physician  should  act  guardedly  and  give  himself  time 
for  a  correction  of  his  diagnosis,  should  this  be  necessary.  Rose- 
ola is  usually  caused  by  some  derangement  of  the  digestive 
apparatus,  but  it  occasionally  complicates  other  diseases.  Dr. 
Eustace  Smith  says  that  it  may  come  on  in  the  "  pre-eruptive 
stage  of  small-pox,  and  is  apt  to  occur  in  vaccinated  children, 
and  in  rheumatic  subjects." 

(317) 


318  1HE  DISEASES  OF  CHILDREN. 

Symptoms. — Signs  of  stomach  disturbance,  more  or  less  pro- 
nounced, usually  precede  or  accompany  roseola.  Sometimes 
vomiting  or  diarrhea  is  present,  but  this  is  not  uniformly  so. 
It  frequently  happens  that  a  child  in  previous  good  health  is 
suddenly  attacked  with  symptoms  of  indigestion,  such  as  nausea 
or  vomiting,  anorexia,  headache  and  a  furred  tongue,  and  soon 
thereafter  a  fever  of  more  or  less  intensity,  accompanied 
with  an  efflorescence  on  the  external  surface,  makes  its  appear- 
ance. The  eruption  is  very  irregular  in  its  manifestation,  some- 
times covering  only  a  meager  portion,  and  again  extending 
over  the  entire  body.  The  eruption  is  quite  similar  to  erysip- 
elas, but  lacks  its  puffy  character.  It  is  without  elevation  of 
the  surface,  and  is  evenly  diffused  over  the  affected  part. 

In  these  respects  it  strongly  resembles  scarlet  fever.  If  a  cold 
is  at  the  foundation  of  the  gastric  disturbance,  a  sore  throat 
may  complicate  the  symptoms  and  make  the  differential  diag- 
nosis between  roseola  and  scarlet  fever,  a  problem  of  extreme 
delicacy.  Some  years  ago  I  was  called  in  counsel  by  my  asso- 
ciate. Dr.  Schneider,  to  see  a  case  which  well  illustrates  the  dif- 
ficulties which  sometimes  present  themselves  in  such  cases. 
Mrs.  F.  had  issued  cards  for  a  garden  party,  to  which  a  large 
number  of  children  were  included;  Two  days  before  the  fete, 
her  youngest  child — a  little  girl  four  years  old — was  taken  ill 
with  high  fever,  sore  throat  and  a  generally  diffused  scarlet 
efflorescence.  The  child  had  vomited  twice  before  my  arrival, 
at  ten  o'clock  P.  M.  The  question  of  diagnosis  was  a  vital  one. 
If  it  was  scarlet  fever,  the  invitations  to  the  garden  party  must 
be  recalled  in  the  morning;  but  if  it  was  only  a  transient  illness, 
without  danger  of  contagion,  there  was  no  necessity  therefor. 
I  gave  the  case  a  very  thorough  examination.  The  tempera- 
ture was  104°  Fahr,;  there  was  a  distinct  angina,  with  a  slight, 
but  perceptible  exudation  on  the  right  tonsil ;  the  body  was 
fairly  ablaze  with  a  scarlatinous  or  erysipelatous  blush.  I  was 
on  the  point  of  pronouncing  the  case  clearly  an  attack  of  scar- 
latina, when  the  mother  said,  "  I  am  sure  this  is  only  an  indi- 
gestion, for  she  has  had  two  attacks  just  like  this  before  and 
was  as  well  as  ever  the  next  day." 

In  view  of  this  statement,  which  was  confirmed  by  Dr. 
Schneider,  I  advised  waiting  until  morning,  before  deciding  on 
the  diagnosis  and  recalling  the  invitations.  To  my  surprise, 
and  greatly  to  the  gratification  of  all  concerned,  I  found,  on 
my  visit  next  morning,  a  complete  change  in  the  whole  picture. 
The  temperature  was  normal,  the  throat  symptoms  were  nearly 
gone;  the  rash  had  almost  disappeared,  and  the  child  was 
pleading  to  be  dressed  and  to  go  out  to  play. 

Better  counsel,  however,  prevailed ;  the  child  was  confined  to 


ROSEOLA.  319 

bed  that  day,  the  diet  was  restricted  and  the  party  was  allowed 
to  proceed  without  any  bad  results  following. 

My  friend,  Dr.  W.  A.  Edmonds,  in  his  work  on  "  Diseases  of 
Children,"  takes  a  very  different  view  of  this  disease  and  insists 
on  its  possessing  a  decidedly  contagious  character.  He  says: 
"  My  clinical  experience  has  decidedly  inclined  me  to  consider 
it  contagious,  as  I  have  rarely  seen  a  case  in  a  family  of  several 
children,  which  was  not  followed  by  others,  just  as  we  see  in 
rubeola  and  scarlet  fever."  He  further  says:  *'  I  do  not  think 
I  have  ever  seen  but  one  individual  have  the  second  attack, 
and  that,  an  individual  of  peculiar  susceptibility  to  contagion, 
as  he  has  had  scarlatina,  rubeola,  yellow  fever,  and  roseola,  each 
a  second  time." 

It  is  difficult  to  account  for  such  a  variance  of  opinion  based 
upon  clinical  experience,  but  differ  as  we  may  upon  other  points, 
all  observers  are  agreed  that  the  disease  is  uniformly  mild  ;  that 
it  is  of  short  duration,  and  devoid  of  complications  and  sequelae. 
The  disappearance  of  the  eruption  is  not  followed  by  desqua- 
mation. 

Diagnosis. — The  appearance  of  the  rash  is  so  nearly  like  that 
of  scarlet  fever,  and,  as  we  have  seen,  there  is  liability  of  the 
occurrence  of  an  incidental  angina,  so  that  the  diagnosis  will 
often  be  in  doubt  for  a  few  hours  after  the  onset  of  an  attack ; 
but  a  short  time  will  suffice  to  clear  up  all  doubts.  The  fever 
of  roseola  rarely  lasts  over  twenty-four  hours,  while  that  of 
scarlet  fever  does  not  abate  or  even  ameliorate  until  the  subsi- 
dence of  the  eruption,  which  ordinarily  does  not  occur  until 
after  the  lapse  of  several  days.  In  roseola  there  is  wanting  the 
characteristic  tongue,  the  mental  symptoms  and  the  evidences 
of  nervous  shock  which  usually  characterize  the  graver  disease. 

Prognosis. — This  is  always  favorable. 

Treatment. — Remedial  measures  are  scarcely  called  for  in  a 
disease  so  benign  and  so  devoid  of  danger  as  this,  but  the  clin- 
ical fact,  which  is  universally  recognized,  that  the  affection  is 
dependent  on  gastric  derangement,  would  suggest  the  employ- 
ment of  such  drugs  as  would  restore  the  normal  tone  and  func- 
tion of  the  digestive  apparatus.  In  the  beginning  of  the  attack, 
the  fever  may  be  aborted  by  aconite  and  belladonna. 

After  one  or  both  of  these  have  been  given  for  a  few  hours, 
such  remedies  as  arsenicum,  nux  vomica  or  laurocerasus  may 
be  given.  The  bowels  should  be  opened  by  warm-water  ene- 
mata  if  necessary,  and  for  a  day  or  two  the  diet  should  be 
restricted. 

In  many  cases  of  mild  type  no  medication  at  all  will  be 
necessary. 


320 


THE  DISEASES  OF  CHILDREN. 


DIFFERENTIAL  DIAGNOSIS   OF   ERUPTIVE   FEVERS   OF 
CHILDHOOD. 


Measles. 

ROTHELN. 

Scarlatina. 

Roseola. 

Incubation. 

7-12  days. 

7-14  days. 

Few  hours  to 
seven  days. 

None 
perceptible. 

Prodroma. 

3-5  days. 

None. 

None. 

None. 

Initial 
Symptoms. 

Acute 
coryza. 

Fever  and 
rash. 

Vomiting, 
fever  and  rash. 

Fever  and 
indigestion. 

Duration. 

9-14  days. 

3-7  days. 

7-42  days. 

A  few  hours  to 
several  days. 

Complications. 

Bronchitis, 
pneumonia. 

Scarcely 
anything. 

Acute 

albuminuria 

or  Bright's 

disease. 

Gastric 

irritation, 

constipation 

or  diarrhea. 

Sequele. 

Eye  and  ear 
troubles. 

None. 

Almost 
everything. 

None. 

Special 
Symptoms. 

Coarse  rash, 

loose  cough, 

tongue 

moist  and 

white. 

Coarse  rash, 

no  cough, 
tongue  slight- 
ly coated  or 
not  at  all. 

Fine  rash,  no 
cough,  tongue 
heavily  coated 
48  hours,  then 
reddish  raised 
papille. 

Fever, 
vomiting. 

Brain. 

Unaffected. 

Unaffected. 

Delirium. 

Temperature. 

100O-102O  or 
103O 

Rarely  over 
100° 

I02°-I07° 

ioo°-i03° 

Skin. 

Sometimes 

slight 

desquamation. 

No 
desquamation. 

Nearly  always 
general  des- 
quamation. 

Dry  and  hot. 

Contagious. 

Highly  so. 

Moderately  so 

Highly  so. 

Never. 

Eruption. 

Dull  red, 
crescentic. 

Pale,  red, 
irregular. 

.  ^Bright  red, 
'  diffusely. 

Fine  rose- 

colored  and 

generally 

local. 

Eruption 
appears  first. 

Forehead  and 
face. 

Face. 

Face,  neck 
and  chest. 

Uncertain. 

Eruption — 

extension  over 

body. 

3  days. 

2  days. 

2  days. 

DIFFEREN  TIA  L  DIA  GNOSIS. 


321 


DIFFERENTIAL   DIAGNOSIS   OF   ERUPTIVE   FEVERS   OF 

CHILDHOOD. — Continued. 


Measles. 

ROTHELN. 

Scarlatina. 

Roseola. 

Throat  and 
palate. 

Slight 

sore  throat, 

dark  spots  on 

palate. 

Rarely 
affected. 

Always  more 
or  less  sore. 

Uncertain. 

Glands. 

Rarely 
involved. 

Never 
seriously 
affected. 

Generally 

enlarged  and 

painful. 

Unaffected 
usually. 

Prognosis. 

Generally 
favorable. 

Always 
favorable. 

Always 
guarded. 

Always  good. 

D.  C— 21 


CHAPTER  VI. 

VARICELLA  (CHICKEN-POX). 

Varicella,  or  as  it  is  more  often  called,  chicken-pox,  is  the 
mildest  of  all  the  eruptive  fevers.  It  is,  however,  highly  con- 
tagious, so  that  few  children  escape  who  are  exposed  to  it.  It 
is  confined  almost  wholly  to  early  childhood,  and  attacks  the 
same  individual  but  once.  It  is  quite  inclined  to  be  epidemic 
in  its  nature.  West  seems  inclined  to  derive  the  word  chicken 
in  this  connection  from  the  mildness  of  the  disease.  It  has 
been  thought  by  some  to  prevail  principally  before,  during  or 
after  epidemics  of  small-pox,  and  hence  it  was  conjectured  to  be 
a  modified  form  of  variola ;  hence  its  name  varicella,  signifying 
little  variola.  This  idea  is  not  entertained  at  the  present  day, 
because  clinical  experience  is  opposed  to  it.  It  has  been  found 
that  varicella  may  occur  after  variola,  and  variola  after  vari- 
cella. So  that  the  one  is  no  protection  against  the  other.  Be- 
sides, the  two  diseases  are  very  dissimilar  as  to  duration,  gravity, 
and  the  time  of  life  at  which  they  are  most  prevalent. 

Varicella  is  peculiar  to  infancy  and  childhood.  Dr.  J.  Lewis 
Smith  and  Prof.  Austin  Flint  have  each  observed  one  case  of. 
the  disease  in  an  adult,  but  such  an  occurrence  is  very  rare. 

Moreover,  M.  Delpech  and  others  have  seen  varicella  and 
variola  occur  simultaneously  in  the  same  individual.  The  dis- 
ease varies  somewhat  in  the  amount  of  eruption  and  the  inten- 
sity of  the  attendant  symptoms,  but  it  is  always  mild,  and  is 
free  from  complications  and  sequelae. 

The  disease  derives  its  chief  interest  and  importance  from 
its  liability  to  be  confounded  with  variola,  a  mistake  which 
has  been  made,  in  spite  of  the  great  dissimilarity  in  symptoms 
and  course. 

Symptoms. — The  constitutional  disturbances  which  mark  the 
stage  of  invasion  in  varicella  are  exceedingly  variable.  In  typ- 
ical cases  the  disease  is  ushered  in  by  a  mild  fever,  the  tem- 
perature rarely  going  above  ioi°  Fahr.,  and  the  pulse  rarely 
exceeding  io8  or  112  per  minute. 

It  is  not  unusual  for  the  patient  to  complain  of  headache, 
languor,  chilliness,  and  sometimes  aching  in  the  back  or  limbs. 
In  some  cases  the  fever  is  entirely  absent,  or  so  slight  as  to  es- 
cape notice.     The  appetite  is  rarely  lost,  and  there  is  no  inter- 
(322) 


VARICELLA   {^CHICKEN-POX).  323 

ruption  to  the  child's  amusements.  When  fever  is  present  it 
usually  lasts  for  twenty-four  or  thirty-six  hours,  when  the  char- 
acteristic eruption  makes  its  appearance.  This  consists  of  small, 
scattered  papules,  which  in  a  few  hours  become  vesicular.  This 
rapid  vesiculization  of  the  papules  is  a  marked  and  distinctive 
feature  of  the  disease.  The  papules  are  not  hard  and  situated 
on  an  inflamed  base,  like  those  of  variola,  although  they  are 
sometimes  surrounded  by  a  faint  zone  of  redness.  The  vesicles 
do  not,  except  very  rarely,  become  umbilicated,  and  are  of 
various  sizes  and  shapes  ;  some  being  small,  round  and  acumi- 
nate, while  others  are  large,  oval  or  elongated.  The  size  varies 
from  half  a  line  in  diameter  to  two  or  even  three  lines.  A 
peculiarity  of  these  vesicles  is  that  they  appear  in  successive 
crops,  and  finally  disappear  by  dessication. 

Sometimes  permanent  cicatrices  are  left,  but  this  is  generally 
due  to  the  premature  rupture  of  the  vesicles  by  scratching. 
The  pruritis  is  frequently  almost  intolerable.  The  eruption  of 
varicella  is  generally  in  the  upper  portion  of  the  body,  either 
on  the  back  or  chest.  From  whatever  part  the  eruption  begins, 
it  rapidly  extends  over  the  body,  the  face,  scalp  and  extremities. 
The  distribution  of  the  rash  is  variable.  In  exceptional  cases 
there  may  not  be  more  than  a  dozen  or  twenty  vesicles  all 
told,  while  in  others  the  number  may  mount  up  into  the  hun- 
dreds, covering  the  whole  cutaneous  surface.  The  eruption,  as 
a  rule,  is  most  abundant  and  characteristic  on  the  forehead  and 
temples.  The  vesicles  do  not  tend  to  become  confluent.  As 
they  mature,  many  become  cloudy,  and  the  contents  slightly 
tinged  with  yellow,  from  the  presence  of  a  few  pus  cells ;  but 
according  to  Fox,  they  never  become  purulent. 

On  the  second  or  third  day,  the  eruption  begins  to  decline, 
the  vesicles  dessicate,  some  grow  tense  and  burst,  or  are  rup- 
tured by  the  scratching  of  the  patient,  when  they  form  their 
yellowish  or  brownish  crusts.  These  disappear  in  a  few  days, 
leaving  small  circular  patches  of  reddened  skin. 

The  eruption  affects  the  mucous  membrane  as  well  as  the 
skin.  The  vesicles  are  thickest  on  the  hard  and  soft  palates. 
They  often  form  on  the  prepuce  in  boys  and  in  the  vagina  in 
girls,  in  which  case  they  give  rise  to  much  suffering  and  cause 
trouble  in  urinating. 

Diagnosis. — The  differential  diagnosis  between  varicella  and 
variola,  is  usually  quite  clear,  if  the  following  facts  are  borne 
in  mind : 

The  age  of  the  patient.  Variola  attacks  persons  regardless 
of  age,  while  varicella  is  peculiar  to  infancy  and  early  child- 
hood. The  period  of  invasion  is  different — that  of  varicella  is 
shorter,  wanting  altogether,  the  rash  being  the  first  indication 


324  THE  DISEASES  OF  CHILDREN. 

of  the  presence  of  the  disease.  In  variola  the  period  of  inva- 
sion is  three  days  in  duration,  and  the  symptoms  of  this  period 
are  well  defined.  There  is  a  chill,  a  high  fever,  vomiting,  with 
intense  headache  and  backache. 

These  symptoms  are  never  present  in  varicella.  In  variola 
the  papules  do  not  become  vesicular  until  the  sixth  or  seventh 
day.  In  varicella,  the  macules  become  vesicular  in  from 
twenty-four  to  forty-eight  hours,  and  then  quickly  dry  up  into 
a  light,  easily  detached  crust.  In  variola,  the  eruption  is  most 
abundant  on  the  face,  hands  and  feet,  while  in  varicella,  the 
eruption  is  most  profuse  on  the  back.  The  face,  hands  and 
feet  show  but  few  vesicles. 

The  mild  and  almost  insignificant  character  of  the  febrile 
stage  of  varicella  is  very  different  from  the  intense  fever  which 
attends  variola,  and  in  the  latter  there  is  a  secondary  fever 
marking  the  pustular  stage,  which  is  altogether  wanting  in  the 
former. 

In  typical  cases  of  the  two  diseases,  there  is  but  little  danger 
of  confounding  them  ;  but  when  irregularities  occur,  as  some- 
times happens,  the  physician  will  have  occasion  to  exercise  the 
greatest  care,  to  avoid  falling  into  error.  It  will  not  do  to 
decide  the  question  on  any  one  symptom,  but  the  entire  cate- 
gory must  be  weighed  separately  and  together,  in  order  to 
reach  the  truth. 

The  following  extract  from  the  writings  of  Dr.  John  D. 
Fisher,  of  Boston,  gives  an  admirable  comparative  description 
of  the  two  diseases. 

"  In  most  cases  the  chicken-pox  is,  by  the  experienced 
observer,  easily  and  readily  distinguished  from  the  small-pox. 
When,  however,  the  former  is  extraordinarily  violent,  and  the 
latter  unusually  mild,  the  distinguishing  marks  are  obscure, 
and  the  two  diseases  are  therefore  frequently  confounded.  To 
render  the  distinctions  as  clear  as  possible,  the  more  prominent 
symptoms  of  the  two  diseases  are  here  contrasted  with  each 
other. 

"  In  small-pox  the  fever  is  ushered  in  by  a  cold  stage,  is 
severe  and  continues  three  or  four  days,  and  if  it  declines  or 
ceases  during  the  eruptive  process,  it  commonly  reappears  dur- 
ing the  suppurative  stage,  or  between  the  fifth  and  eighth  day 
of  the  eruption. 

"  In  chicken-pox  the  fever  is  not  often  preceded  by  a  cold 
stage,  is  uniformly  light  and  is  frequently  insensible ;  it  seldom 
continues  more  than  two  days  and  never  reappears  after  it  has 
once  ceased.  When,  however,  the  vesicles  appear  in  successive 
crops,  the  fever  lasts  longer  and  rages  until  the  eruption  is 
completed. 


VARICELLA   {CHICKEN-POX).  325 

"  In  small-pox  the  eruption  is  often  preceded  or  accompanied 
by  an  erysipelatous  efflorescence. 

**  In  chicken-pox  this  efflorescence  does  not  take  place. 

*'  In  small-pox  the  eruption  does  not  break  out  until  the  third 
or  fourth  day  of  the  fever ;  it  appears  first  on  the  face,  then  on 
the  neck,  chest,  trunk  and  extremities,  and  is  completed  in  the 
course  of  two  days. 

"  In  chicken-pox  the  eruption  breaks  out  by  the  termination 
of  the  first  or  on  the  second,  and  almost  invariably  before  the 
end  of  the  third  day  of  the  fever;  it  usually  appears  first  about 
the  breast  and  shoulders,  afterwards  on  the  face  and  extremi- 
ties. It  often,  however,  follows  a  different  order,  and  is  never 
so  uniform  in  the  method  of  its  invasion  as  the  eruption  of 
small-pox  ;  it  frequently  appears  in  successive  crops  for  four  or 
five  days. 

"  In  small-pox  the  eruption  presents  itself  in  the  form  of 
small  red  circular  points  or  papule  ;  these  are  hard,  resisting  and 
movable,  and  communicate  to  the  finger  a  shot-like  sensation. 
They  scarcely  project  above  the  surface,  but  are  easily  and  dis- 
tinctly felt  by  drawing  the  finger  over  them. 

"  In  chicken-pox  the  eruption  likewise  breaks  out  in  small 
inflamed  spots,  but  these  are  not  papular  in  their  origin,  and 
are  not  exactly  circular,  but  tend  to  an  oblong  figure.  They 
may  be  distinctly  felt  by  the  finger,  but  they  are  yielding 
under  it  and  are  destitute  of  the  tubercular  hardness  and  roll- 
ing motion  which  characterize  the  variolous  eruption  at  the 
same  period. 

"  In  small-pox  the  eruption  seldom  becomes  vesicular  be- 
fore the  end  of  the  second  or  the  commencement  of  the 
third  day,  and  the  vesicles  are  confined  to  the  summits  of 
the  pocks. 

"  In  chicken-pox  the  eruption  is  vesicular  from  the  begin- 
ning, or  from  the  early  part  of  the  first  day,  and  by  the  second 
day  the  whole  surface  of  the  pocks  are  converted  into  vesicles 
which  resemble  little  bladders  of  transparent  fluid. 

"  In  small-pox  the  pustules  at  first  have  acuminated  sum- 
mits ;  they  afterwards  become  rounded,  and  at  an  early  period 
present  slight  depressions  in  the  center  of  their  surfaces. 

"  In  chicken-pox  the  vesicles  are  usually  lenticular  in  form, 
but  are  sometimes  conoidal  or  globate,  and  preserve  one  shape 
through  their  course,  or  until  they  become  ruptured. 

"  In  small-pox  the  eruption  is  situated  in  the  substance  of 
the  cutis,  as  has  been  proved  by  dissection,  and  as  is  evident 
from  the  sensation  which  the  pustules  communicate  to  the 
finger. 

"  In  chicken-pox  the  vesicles  are  not  formed  in  the  true  skin, 


326  THE  DISEASES  OF  CHILDREN. 

but  are  situated  upon  its  surface  in  the  cellular  tissue  between 
the  skin  and  cutis. 

"  In  small-pox  the  pustules  after  they  have  become  vesicular 
are  distinguished  by  hard,  unyielding  bases. 

"  In  chicken-pox  the  vesicles  are  destitute  of  such  tubercular 
basis.  They  are  yielding  and  easily  give  way  under  pressure, 
and  communicate  to  the  finger  a  soft,  elastic  sensation,  or  a 
feeling  similar  to  that  which  a  minute  globule  of  fine  sponge 
softened  with  water  would  give  rise  to  when  pressed. 

"  In  small-pox  the  pustules  are  composed  of  little  cells,  all  of 
which,  however,  communicate  with  each  other ;  and  the  cuti- 
cular  covering  of  the  pocks  is  opaque,  tough  and  not  easily 
broken. 

"  In  chicken-pox  the  vesicles  are  composed  of  a  single  cavity, 
and  the  coverings  are  extremely  thin  and  fragile,  are  diapha- 
nous and  are  very  easily  broken. 

"  In  small-pox  the  pustules  are,  at  an  early  stage,  filled  with 
a  serous  secretion  ;  this,  after  a  time,  becomes  converted  into  a 
purulent  matter  that  exhales  a  very  unpleasant  and  peculiar 
odor. 

"  In  chicken-pox  the  vesicles  contain,  when  fully  matured, 
only  a  whitish,  transparent  and  serous  fluid  ;  this  never,  except 
through  accident,  becomes  pus,  and  is  destitute  of  any  ungrate- 
ful odor. 

"  In  small-pox  the  pustules  remain  whole  till  they  are  six  or 
seven  days  old,  when  some  of  them  commonly  become  rup- 
tured, and  permit  a  little  of  the  virus  to  ooze  out  upon  their 
surface ;  but  they  still  retain  their  form  and  prominency. 

"  In  chicken-pox  the  vesicles  often  become  broken  in  two  or 
three  days  after  their  appearance,  and  permit  the  whole  of  their 
contents  to  escape.  Their  coverings  then  sink  down  and  col- 
lapse, and  the  vesicles  become  flattened  and  lose  their  original 
form. 

"  In  small-pox  the  pustules  break  out  simultaneously,  pur- 
sue a  regular  march  and  arrive  at  maturity  at  about  the  same 
time. 

"  In  chicken-pox  the  vesicles  generally  break  out  in  succes- 
sive crops  for  a  number  of  days,  in  which  case  a  great  variety 
may  be  observed  among  them ;  some  are  appearing,  whilst 
others  are  fully  formed,  shriveled  or  crusted. 

"  In  small-pox  desiccation  does  not  commence  till  about  the 
eighth  day  from  the  appearance  of  the  eruption. 

"  In  chicken-pox,  when  the  vesicles  run  their  course  without 
bursting,  desiccation  commences  in  them  as  early  as  the  fifth 
day  of  their  age,  but  it  always  begins  as  soon  as  the  vesicles 
are  ruptured,  and  consequently  it  more  usually  commences  on 


VARICELLA  {CHICKEN-POX).  327 

the  third  or  fourth  day,  and  sometimes  as  early  as  the  second 
day  after  they  appear. 

"  In  small-pox  the  processes  of  eruption,  of  suppuration  and 
of  desiccation  constitute  three  successive  periods,  rendered 
distinct  from  each  other  by  their  duration  ;  the  first  occupies 
about  three  days  and  the  other  two  about  five  days  each. 

"  In  chicken-pox  these  three  periods  seem  to  be  confounded 
in  consequence  of  the  pocks  appearing  in  successive  crops,  and 
even  when  they  are  distinguishable,  the  sum  of  their  duration 
seldom  exceeds  eight  days. 

"  In  small-pox  the  scabs  fall  off  in  a  single  piece. 

"  In  chicken-pox  the  scabs  do  not  usually  fall  off  in  a  single 
piece,  but  in  small  fragments  of  different  forms  and  sizes. 

"  The  small-pox,  even  when  distinct  and  of  moderate  mild- 
ness, is  a  disease  of  fifteen  or  twenty  days  in  duration,  and  it 
often  proves  fatal. 

"  The  chicken-pox,  on  the  contrary,  runs  its  course  and  is 
completed  in  five  or  six  days,  or  in  eight  or  ten  at  most,  and  it 
never,  of  itself,  proves  fatal. 

"  The  distinctions  between  the  chicken-pox  and  the  varioloid 
disease,  or  the  small-pox  in  its  modified  form,  are  less  striking, 
and  less  easily  recognized.  The  following  peculiarities,  how- 
ever, may  generally  be  observed  in  the  two  diseases,  and  will, 
in  most  cases,  lead  to  a  correct  discrimination. 

"  The  chicken-pox,  as  has  already  been  stated,  is  distinguished 
by  the  eruptive  fever  being  generally  light. 

"  In  the  varioloid  disease  the  precursory  fever  is  commonly 
sharp  and  of  several  days'  duration. 

"  In  chicken-pox  the  eruption  appears  in  the  form  of  vesicles, 
or  it  is  vesicular,  at  least,  from  an  early  period  of  the  first  day. 

"  In  the  varioloid  disease  the  eruption  is  always  papular  in 
its  origin,  and  seldom  becomes  vesicular  before  the  second  or 
third  day.  It  appears  all  at  once  and  seldom  breaks  out  in 
successive  crops.  The  pocks  are,  in  the  first  instance,  elevated 
on  solid  tubercular  bases,  and  their  tops  are  resisting  and  not 
easily  broken.  The  eruption,  as  in  the  unmodified  variola,  is 
formed  in  the  substance  of  the  true  skin,  as  is  evident  from 
the  hard  and  elevated  bases  which  remain  after  the  lymph  is 
removed  from  the  pustules  by  puncture  and  pressure,  and  by 
the  kernels  or  tubercular  elevations  which  remain  in  the  skin 
after  the  scabs  have  fallen  off.  The  pocks  from  their  first 
formation  are  hard  and  unyielding,  and  are  movable  and  rolling 
under  the  finger." 

To  these  distinguishing  characteristics,  all  of  which  have 
been  noticed  by  various  writers,  the  author  would  add  the  fol- 
lowing : 


328  THE  DISEASES  OF  CHILDREN. 

"  In  chicken-pox,  if,  during  the  first  day  of  the  eruption,  the 
parts  on  which  it  exists  be  embraced  with  the  thumb  and  finger 
and  gently  distended  by  them  ;  or  if  a  single  finger  be  drawn 
over  them  with  a  force  just  sufficient  to  cause  the  little  ruge  of 
the  cuticle  to  become  smooth,  the  inflamed  spots,  in  which 
form  the  vesicles  first  present  themselves,  readily  disappear  and 
leave  no  discoloration  or  induration  in  the  skin. 

"  In  the  varioloid  disease,  if  a  like  distention  of  the  parts 
occupied  by  the  eruption  be  made  at  the  same  date,  the  in- 
flamed spots  disappear  less  readily  and,  even  when  the  distend- 
ing force  is  sufficiently  great  to  make  them  disappear,  a  dim 
discoloration  can  be  perceived  and  a  distinct  shot-like  hardness 
may  be  felt  at  the  points  upon  which  they  were  planted. 

"  In  chicken-pox  the  scars  left  in  the  skin  after  desquamation 
are  destitute  of  any  peculiar  hardness,  and  are,  in  the  space  of  a 
few  days,  entirely  erased. 

"  In  the  varioloid  disease  the  eruption,  for  a  considerable 
time  after  the  scabs  have  fallen,  leaves  little  kernels,  or  tuber- 
cular elevations,   in  the  skin.     The  varioloid  disease  has  the 

power  of  communicating  the  unmodified  and  modified  small- 
er 
pox. 

In  addition  to  a  careful  study  of  these  distinguishing  feat- 
ures, the  physician  should  ascertain  if  the  patient  has  been 
sucessfuUy  vaccinated  within  five  years  ;  if  so,  the  probability  is 
in  favor  of  varicella,  particularly  if  the  subject  is  a  child,  as 
varicella  rarely  afTects  an  adult. 

Treatment. — The  treatment  of  varicella  does  not  call  for  any 
extended  comment.  Ordinary  cases  will  not  require  any  treat- 
ment. There  is  no  known  prophylactic.  The  disease  will  run 
its  usual  and  discreet  course,  whatever  is  done  or  left  undone. 

VACCINIA — VACCINATION. 

Vaccinia  is  a  mild  eruptive  fever  produced  by  vaccination  for 

the  purpose  of  protecting  the  subject  from  the  graver  disease^ 
small-pox.  It  is  communicable  only  by  contact,  and  is  not  con- 
tagious through  the  air  like  the  other  eruptive  fevers. 

It  is  inoculable  by  the  lymph  contained  in  the  vesicle,  and  also 
by  the  moistened  scab  which  results  from  the  dessication  of  the 
pustule. 

Vaccination  has  now  everywhere  taken  the  place  of  inoculation, 
which  was  the  first  step  which  scientific  medicine  took  to  stamp 
out  that  most  dreaded  of  all  diseases,  small-pox.  For  fifty  years 
— the  latter  half  of  the  eighteenth  century — inoculation  was 
practiced  both  in  Europe  and  in  this  country,  but  so  nrany 
deaths  and  so  much  indirect  suffering  occurred  as  the  result  of 


VA  C  CINIA  —VAC  CINA  TION.  329 

this  method,  that  it  began  to  be  looked  upon  with  distrust. 
The  efficacy  of  the  operation  in  mitigating  the  severity  and 
danger  from  small-pox  was  certainly  very  great,  for  the  propor- 
tion of  deaths  following  it  was,  on  an  average,  only  about  three 
in  a  thousand — a  very  gratifying  contrast  to  the  mortality  of 
the  disease  communicated  in  the  usual  way.  "  But  there  was 
one  fatal  drawback.  However  light  the  engrafted  disease  might 
be,  it  was  still  small-pox ;  and  the  more  it  was  conveyed  in  this 
way,  the  more  were  centers  of  infection  multiplied,  from  which 
those  not  protected  were  liable  to  contract  the  disease  in  its 
worst  form.  To  individuals,  inoculation  was  a  great  blessing ; 
to  society  at  large,  it  was  a  great  curse.  In  the  early  part  of 
the  eighteenth  century,  before  inoculation,  about  one-four- 
teenth of  the  deaths  in  Great  Britain  were  from  small-pox ;  in 
the  latter  part,  after  inoculation  had  become  quite  general, 
about  one-tenth  of  the  deaths  were  from  that  disorder."  *  It 
was  at  this  time  (1796),  when  inoculation  as  a  preventive  of 
small-pox,  had  received  general  recognition,  but  not  general 
adoption,  for  reasons  already  stated,  that  Jenner  demonstrated 
the  great  and  immortal  fact,  that  by  passing  the  small-pox 
virus  through  one  of  the  lower  animals,  especially  the  cow,  it 
could  be  so  modified  as  to  lose  its  contagious  properties  and 
yet,  when  inoculated,  thus  modified,  into  the  human  system,  it 
afforded  all  the  protection  which  resulted  from  the  use  of  the 
genuine  virus. 

Vaccination,  then,  is  the  conveyance  of  small-pox  into  the 
system  of  a  susceptible  human  being,  but  of  a  small-pox 
wonderfully  modified,  and  shorn  of  its  terrors,  by  previously 
passing  it  through  an  animal. 

In  the  process  of  transmission  through  a  lower  animal  organ- 
ism, it  has  in  some  way,  parted  with  its  contagious  property,  so 
that  vaccinated  small-pox,  thus  modified,  is  not  constantly 
spreading  the  disease  as  was  the  case  with  inoculated  small-pox. 
Jenner  demonstrated  that  the  horse  as  well  as  the  cow  could 
be  made  the  subject  of  variolous  infection,  a  fact  that  has  been 
repeatedly  verified  since  his  day.  At  present,  however,  the 
cow  is  practically  the  only  source  of  original  supply  of  vaccine 
virus  ;  indeed,  the  term  vaccination  is  derived  from  "  vacca,"  "  a 
cow." 

No  other  discovery  in  the  whole  history  of  medicine  com- 
pares with  that  of  Jenner,  in  relieving  human  suffering  and 
saving  human  life  ;  and  if  vaccination  were  only  universally 
employed,  there  is  every  reason  to  believe  that  small-pox  would 
be  wiped   from  the  face  of  the  earth.     In  Chicago  there  is  a 


•  Dr.  W.  T.  Plant,  in  "  Cyclopedia  of  Diseases  of  Children. 


330  THE  DISEASES  OF  CHILDREN. 

constant  inspection  of  all  the  pupils  attending  the  public 
schools,  and  no  child  is  permitted  to  attend  school  without  a 
certificate,  showing  recent  vaccination.  During  the  year  end- 
ing December  31,  1892,  small-pox  made  its  appearance  five 
times,  but  in  every  instance  the  source  of  contagion  was  traced 
to  foreign  countries,  and  in  a  population  of  1,250,000  people, 
there  were,  during  this  year,  but  two  deaths  from  small-pox. 
The  opponents  of  vaccination  need  no  other  answer  than  to 
contrast  this  almost  complete  exemption  with  the  annual 
mortality  from  this  disease  in  all  countries  one  hundred 
years  ago. 

The  Virus. — Until  a  comparatively  recent  period,  the  source 
of  supply  of  fresh  animal  virus  was  so  uncertain  and  precarious 
that  the  custom  prevailed  of  using  lymph  from  the  human  sub- 
ject, and  thus  transmitting  the  vaccine  disease  from  one  person 
to  another. 

But  the  danger  of  inoculating  healthy  persons  with  constitu- 
tional taints,  such  as  struma,  psora,  and  syphilis,  came  to  be 
regarded  as  so  great  that  of  late  years  this  source  of  supply  has 
been  nearly  abandoned.  Besides,  it  is  believed  that  the  virus 
thus  procured,  after  many  transmissions,  becomes  so  attenuated 
as  to  be  of  uncertain  efficacy.  For  these  reasons  it  is  now  the 
general  custom  to  use  only  bovine  virus,  procured  directly  from 
the  cow.  In  order  to  keep  up  a  uniform  and  reliable  supply 
of  this  virus,  there  have  been  established  numerous  "vaccine 
farms,"  in  different  parts  of  the  country,  where  young  heifers 
are  constantly  subjected  to  the  process  of  propagation.  From 
these  "  farms,"  or  vaccine  establishments,  the  lymph  is  distrib- 
uted by  mail  or  express  as  needed,  to  all  parts  of  the  world. 

The  virus  is  dispensed  either  in  the  form  of  scabs,  or  on 
ivory  points  that  have  been  dipped  in  the  fresh  lymph  of  a 
punctured  vesicle.  The  latter  is  decidedly  the  more  preferable, 
as  the  ivory  point  makes  an  admirable  vaccinator. 

It  should  be  borne  in  mind  that  vaccine  virus,  whatever  be 
its  source,  is  very  perishable,  and  soon  loses  its  efificacy  if  ex- 
posed to  light,  air,  warmth,  or  moisture.  Cold  does  not  affect 
it,  and  with  proper  precautions  it  may  be  kept  indefinitely. 

Vaccination. — Vaccination  is  the  slight  surgical  operation 
necessary  to  insert  the  virus,  and  consists  in  getting  an  abraded 
or  denuded  surface  of  small  area,  on  which  the  moist  virus  is 
placed  and  allowed  to  dry. 

The  exact  site  where  the  vaccination  is  to  be  performed  is 
optional,  but  generally  the  arm  or  leg  is  selected.  If  the  former, 
the  outer  aspect  of  the  left  arm  is  preferred,  at  or  near  the 
insertion  of  the  deltoid  muscle.  With  females  we  prefer  to  use 
the  leg — it  matters  not  which — for  the  reason  that  in  a  certain 


VA  C  CfNIA  —VAC  CINA  TION.  331 

proportion  of  vaccinations,  no  matter  how  fresh  and  pure  the 
virus  nor  what  amount  of  care  is  exercised  in  the  operation,  an 
excessive  amount  of  inflammation  and  suppuration  will  ensue 
and  in  consequence  a  scar  will  result  which  on  the  arm  will 
ever  after  be  an  unsightly  blemish.  Even  with  boys  we  prefer 
the  leg,  on  account  of  the  greater  facility  with  which  it  can  be 
inspected  and  if  necessary,  treated. 

When  the  leg  is  chosen  for  the  operation,  the  virus  should 
be  inserted  at  about  the  outer  edge  of  the  gastrocnemius  mus- 
cle, midway  of  its  length. 

The  ordinary  instrument  used  for  vaccination  —  when  a 
special  instrument  is  used  at  all — is  the  common  lancet.  This 
should  be  perfectly  clean,  and  care  should  be  taken  not  to 
draw  blood,  if  possible. 

The  epidermis  may  be  scraped  until  the  cutis  is  exposed  and 
a  little  serum  exudes.  This  scraping  should  be  over  a  surface 
from  a  quarter  to  half  an  inch  square.  On  this  abraded  sur- 
face the  virus,  moistened  just  enough  to  "  revive,"  is  placed 
and  allowed  to  dry.  It  is  never  best  to  cover  the  wound 
with  plaster  or  bandage  immediately  after  the  operation,  for 
the  reason  that  either  is  liable  to  absorb  the  lymph  before  the 
skin  is  able  to  do  so. 

A  better  method  than  that  just  described  is  to  scarify  the 
necessary  surface  with  the  ivory  point,  which  is  made  sharp  at 
the  charged  end  expressly  for  this  purpose.  A  dozen  or 
twenty  linear  incisions  should  be  made,  all  quite  superficial, 
and  from  half  a  line  to  a  line  apart  ;  then  as  many  cross  inci- 
sions should  be  made  in  like  manner,  after  the  manner  of  a 
checker  board.  If  some  blood  is  drawn,  as  is  most  always  the 
case,  it  should  be  wiped  up  with  a  clean  cloth  or  a  blotter. 
The  ivory  point,  slightly  moistened  in  cold  water,  should  then 
be  rubbed  over  the  surface  and  the  moisture  allowed  to  dry  as 
before. 

Painless  Vaccination. — Whichever  of  the  foregoing  meth- 
ods is  chosen,  there  is  some  pain,  or  at  least  some  discomfort 
with  it.  Some  children  are  much  more  susceptible  to  pain 
than  others.  Few  parents  like  to  see  their  infants  hurt,  and  to 
the  onlooker  the  operation  of  scraping  or  scarifying  the  delicate 
skin  of  a  young  infant  seems  a  barbarous  procedure. 

All  of  this  can  be  avoided  if  the  physician  will  but  take  the 
trouble,  and  the  vaccination  can  be  successfully  done  while  the 
child  is  peacefully  slumbering.  The  author  does  not  know  to 
whom  he  is  indebted  for  this  painless  method,  but  he  has  em- 
ployed it  for  many  years  past  and  in  scores,  if  not  in  hundreds, 
of  cases.     It  is  believed  to  be  a  superior  method,  not  alone 


332  THE  DISEASES  OF  CHILDREN. 

because  it  saves  suffering,  but  because  it  is  more  uniformly 
successful  in  results  than  any  other. 

The  plan  is  to  apply  to  the  arm  or  leg  of  the  child,  a  few 
hours  before  the  operation — say  the  night  previous — a  piece  of 
adhesive  plaster  an  inch  square,  in  the  center  of  which  has 
been  placed  a  mere  dot  of  Spanish-fly  blister.  The  fly  oint- 
ment should  be  used,  as  the  powder  deteriorates  very  rapidly, 
and  care  should  be  taken  that  the  ointment  is  fresh  or  disap- 
pointment will  ensue.  After  the  lapse  of  a  few  hours,  the  piece 
of  plaster  is  to  be  carefully  removed,  and  a  small  blister  will  be 
found  on  the  site  of  the  cantharides.  This  should  be  punc- 
tured and  the  serum  let  out,  and  on  this  denuded  surface  of  the 
cutis  vera  the  virus  is  placed,  just  as  in  the  other  methods. 
Care  must  be  taken  not  to  make  too  large  a  blister.  The 
amount  of  cantharides  should  be  the  smallest  possible — the 
merest  dot — less  in  size  than  the  head  of  an  ordinary  pin. 

Symptoms  and  Course. — For  a  period  varying  from  three 
days  to  a  week  there  are  no  visible  or  perceptible  phenomena. 
The  virus  is  in  process  of  incubation.  On  the  third  or  fourth 
day  a  small,  hard  papule  makes  its  appearance  at  the  point  of 
operation.  In  the  course  of  twenty-four  or  forty-eight  hours 
this  papule  becomes  a  vesicle,  and  in  another  day  it  has  be- 
come umbilicated  and  divided  into  eight  or  ten  cells  or  com- 
partments— in  this  respect  acting  precisely  like  the  genuine 
small-pox  vesicle.  By  the  eighth  or  ninth  day  after  the  opera- 
tion the  vesicle  has  matured  and  attained  its  complete  develop- 
ment. It  is  raised  prominently  above  the  surface  and  is  dis- 
tended with  transparent  fluid.  This  fluid  is  the  lymph  used 
for  subsequent  vaccinations  where  human  virus  is  employed. 

When  desired  for  this  purpose,  the  vesicle  should  be  punc- 
tured— never  later  than  the  ninth  day — and  carefully  preserved 
in  a  cool  place,  unless  used  immediately.  At  this  time,  a  belt 
of  inflammatory  redness  forms  about  the  base  of  the  vesicle,  or 
pustule,  as  it  has  now  become.  This  is  the  characteristic  areola, 
which  indicates  successful  vaccination.  For  several  days  the 
areola  widens  until  it  attains  a  diameter  of  two  or  three  inches. 
There  is  now  considerable  induration  ;  the  flesh  is  hard,  hot, 
itchy  and  painful.  As  these  phenomena  develop,  there  are  con- 
stitutional symptoms  evolved,  such  as  fever,  headache,  rigors 
and  general  aching.  The  member  operated  on  is  apt  to  be 
lame  and  painful.  Not  infrequently  the  axillary  or  inguinal 
glands  become  swollen  and  tender.  This  state  of  afTairs  is  of 
short  duration.  After  the  tenth  day  all  inflammatory  symptoms 
decline,  and  the  constitutional  disturbance  abates.  The  local 
pain,  the  itching  and  the  swelling  rapidly  decrease  ;  the  areola 
fades  away ;  the  fluid  in  the  vesicle  loses  its  translucence  and 


VA  C CINIA—  VA  C CINA  TION.  333 

speedily  dries  down  into  a  hard,  dark  crust,  which  falls  off  about 
the  twenty-first  day,  leaving  a  circular,  depressed  scar,  at  first 
red,  but  soon  pale,  which  commonly  lasts  through  life. 

Deviations  and  Complications.  —  While  vaccination  ordi- 
narily runs  a  regular  course,  one  phenomenon  following  another 
in  systematic  order,  this  is  not  always  so,  and  deviations  from 
the  rule  are  sometimes  met  with,  for  which  the  physician  is  un- 
justly blamed.  The  cases  where  vaccinia  produces  more 
than  temporary  illness,  as  above  described,  are  rare,  and  when 
eczema  or  erysipelas  supervenes,  or  extensive  suppuration 
occurs,  it  is  generally  attributable  to  a  constitutional  defect  in 
the  child,  rather  than  to  the  impurity  of  the  vaccine  virus,  or 
an  illy  performed  vaccination.  It  is  quite  possible  for  diseases 
and  tendencies,  that  have  been  hitherto  latent,  to  be  stirred 
into  activity  by  this  operation,  but  surely,  in  such  cases,  the 
unexpected  results  should  not  be  charged  to  the  operation 
itself,  which,  as  a  rule,  is  so  free  from  danger  and  so  benign  in 
its  effects. 

The  question  is  often  asked,  as  to  the  degree  and  duration  of 
the  protection  against  small-pox,  which  is  afforded  by  vaccina- 
tion. There  have  been  exceptional  cases  recorded,  in  which 
vaccinated  persons  have  contracted  variola,  notwithstanding 
they  could  show  a  characteristic  scar.  In  such  cases  the  immu- 
nity is  only  partial,  and  a  modified  small-pox  is  possible.  Dr. 
Buchanan,  of  London,  has  carefully  compiled  statistics  of 
deaths  from  variola  among  the  vaccinated  and  the  unvaccinated, 
from  which  it  appears  that  the  death  rate  from  small-pox, 
among  those  who  were  vaccinated  in  infancy,  is  40  per  million, 
while  the  death  rate  from  this  cause  among  the  unvaccinated  is 
5.950. 

Among  those  vaccinated  in  infancy  or  early  childhood,  there 
is  undoubtedly  a  tendency  to  outgrow  the  protective  virtues  of 
the  operation.  There  is  a  general  impression  that  such  vacci- 
nations should  be  repeated  after  puberty  is  passed.  Dr.  Martin 
is  quoted  as  saying  that  he  has  succeeded  in  re -vaccinating  with 
bovine  virus  in  seventy-three  per  cent,  of  the  cases  in  which  he 
has  tried  it.  In  case  of  exposure,  re-vaccination  should  be 
performed,  unless  a  prior  vaccination  has  been  successful  within 
five  or  six  years,  whether  in  child  or  adult. 

It  occasionally  happens  that  a  child  is  vaccinated  one  or 
more  times  without  typical  results.  In  such  cases  the  fault  is 
presumably  the  fault  of  the  virus  or  the  operator  rather  than 
the  subject.  It  is  believed  that  susceptibility  to  vaccinia  is 
universal  and  without  exception.  Dr.  Plant  is  authority  for  the 
statement  that  of  upwards  of  nine  thousand  operations  done  at 
the  Blackfriars  Station  of  the  National  Vaccine  Establishment 


334  THE  DISEASES  OF  CHILDREN. 

since  1859,  there  was  but  one  single  case,  which  on  a  second 
trial  was  unsuccessful.  There  may  be  cases  in  which  for  a  time 
the  system  may  have  lost  its  susceptibility,  as  when  pre-occu- 
pied  by  some  other  disease  or  perturbation  ;  but  this  is  undoubt- 
edly only  for  a  limited  time  and  in  a  very  limited  number  of 
individuals.  It  is  hardly  possible  for  it  to  extend  over  a  life- 
time in  the  face  of  so  much  opposite  experience. 

The  age  at  which  vaccination  should  be  performed  is  worthy 
of  a  moment's  consideration.  Nearly  all  countries  require  that 
it  be  done  before  the  end  of  the  first  year.  In  England,  the 
Vaccination  Act  of  1867,  requires  the  operation  to  be  per- 
formed "  within  three  months  of  birth,  or  as  soon  afterwards  as 
the  public  arrangements  of  the  district  in  which  the  family 
lives  will  afford  opportunity  of  obtaining  gratuitous  vaccina- 
tion." It  should  be  done  in  all  cases  before  dentition  begins 
or  between  the  first  and  fourth  months.  In  case  the  child  is 
out  of  health  or  has  any  skin  eruption,  it  should  be  got  in  good 
condition  before  the  operation. 

In  case  small-pox  is  prevailing  in  the  vicinity,  there  is  no 
reason  for  postponement  either  on  account  of  age  or  bad  phys- 
ical condition. 

Wolff  {Berl.  Klin.  Woch.,  No.  17,  1889),  reports  the  vaccina- 
tion of  eight  new-born  infants,  one  of  two  days  old,  with 
humanized  lymph,  and  has  observed  in  them  the  normal  devel- 
opment of  the  pustule,  with  a  complete  absence  of  the  vaccine 
fever.  An  equally  good  result  was  observed  in  thirty-four  other 
new-born  infants,  in  ten  of  which  the  mothers  were  vaccinated 
immediately  before  birth.  Fifteen  newborn  infants  were  inoc- 
ulated with  animal  lymph,  and  quite  as  many  were  successful 
as  is  the  case  in  older  children.  The  only  point  of  remark  in 
the  two  sets  of  inoculation  was  the  much  higher  maximum  of 
temperature  reached  in  the  cases  in  which  animal  virus  was 
used.  The  author  concludes  that  new-born  infants  are  equally 
susceptible  with  older  children  to  vaccination  ;  that  the  opera- 
tion is  attended  with  no  danger,  and  that  in  times  of  variola 
epidemics  the  new-born  babes  should  be  vaccinated  without 
delay. 

The  season  of  year  seems  to  have  no  special  bearing  on 
the  subject.  In  summer  and  winter  the  course  of  vaccinia 
is  the  same.  An  unprotected  infant,  no  matter  how  young, 
who  is  about  to  travel  in  a  public  conveyance  should  always  be 
vaccinated  before  starting. 

After  Treatment. — Although  in  any  case  the  amount  of 
suffering  attendant  on  vaccinia  is  but  trifling,  when  compared 
to  that  of  the  horrible  disease  which  it  seeks  to  prevent,  still 
there  are  cases  where  the  pruritis  is  very  distressing,  and  where 


VA  C  CINIA—  VA  C CINA  TION.  335 

the  amount  of  inflammation  exceeds  the  ordinary  boundaries  and 
some  means  of  alleviation  are  called  for.  In  the  case  of  young 
children,  the  desire  to  relieve  the  itching  by  scratching  is  al- 
most uncontrollable,  and  there  is  danger  of  interfering  with  the 
integrity  and  completeness  of  the  process,  if  this  be  permitted. 
To  avoid  it,  the  vaccination  should  be  covered  with  a  dossil  of 
lint  wet  with  olive  oil  and  held  in  place  with  a  few  turns  of  a 
bandage,  the  ends  of  which  should  be  secured  by  a  few  stitches. 
If  there  is  considerable  local  fever,  with  swelling  and  tender- 
ness, much  relief  will  be  given  by  the  occasional  application  of 
dilute  Goulard's  lotion  (sub-acetate  of  lead,  one  part  to  ten  of 
water).     Still  better  is  witch  hazel  (hamamelis). 

In  cases  of  exceptional  violence,  tending  to  gangrene,  erysip- 
elas, or  septicemia,  active  measures,  both  medicinal  and  local, 
should  be  used,  just  as  if  the  same  condition  had  resulted  from 
other  causes. 


PARX     VI- 

NON-ERUPTIVE  CONTAGIOUS  DISEASES. 


CHAPTER  I. 

DIPHTHERIA. 

Definition. — Diphtheria  is  an  acute,  specific  and  highly  dan- 
gerous affection,  the  principal  local  manifestations  of  which 
consist  in  the  formation  of  more  or  less  extensive  patches  of 
pseudo-membrane  upon  and  within  the  mucous  surfaces  of  the 
pharynx,  larynx  and  nose.  Occasionally  it  affects  other  sur- 
faces. It  is  inoculable,  infectious  and  contagious,  and  is  both 
endemic  and  epidemic.  Nearly  all  authorities  are  agreed  that 
frequently  it  occurs  sporadically.  Most  cases  are  attended  with 
swelling  of  the  cervical  glands.  Clinically,  the  disease  is 
marked  by  great  constitutional  weakness,  by  irregular  fever  of 
low  type ;  frequent  albuminuria ;  by  tedious  and  uncertain 
convalescence ;  by  a  tendency  to  toxemia  which  may  result  in 
heart  failure ;  and  by  peculiar  paralytic  sequele. 

It  is  by  no  means  a  new  disease.  As  far  back  as  medical 
records  go,  we  find  described  a  disease  of  the  throat  and  upper- 
air  passages,  so  strikingly  like  that  which  we  now  call  diph- 
theria, that  their  identity  is  indisputable. 

Sir  Morell  McKenzie,  in  his  "  Treatise  on  the  Diseases  of 
the  Throat  and  Nose,"  says :  "  Centuries  before  the  time  of 
Hippocrates,  an  Indian  writer  had  included  in  his  System  of 
Medicine,  a  description  of  a  disease,  entirely  analagous  to  the 
one  under  consideration.  This  work  was  originally  written  in 
Sanskrit,  but  a  Latin  translation  was  made  of  it  by  F.  Hessler, 
and  published  in  1844,  a  copy  being  in  the  British  Museum. 
The  writer  says  the  disease  is  characterized  by  an  increase  of 
phlegm  and  blood  which  causes  a  swelling  in  the  throat, 
attended  with  pain  and  panting,  destroying  the  vital  organs 
and  incurable.  He  also  says :  'A  large  swelling  in  the  throat, 
impeding  food  and  drink,  and  marked  by  violent  feverish  symp- 
toms, obstructing  the  passage  of  the  breath,  arising  from 
phlegm  combined  with  blood,  is  called  "closing  of  the  throat."*' 
(336) 


DIPHTHERIA.  337 

All  of  the  older  writers,  whose  works  have  been  preserved, 
describe  in  varying  language  a  similar  disease  and  note  the  ter- 
rible mortality  attending  it.  Asclepiades  is  always  cited  in  this 
connection  as  being  the  first  to  perform  laryngotomy.  Are- 
teus  of  Cappadocia,  Galen,  Celius  Aurebianus  and  other 
contemporaneous  writers  describe  it.  In  the  fifth  century  Aetius 
advised  against  energetic  local  treatment  and  the  forcible 
removal  of  the  deposits  before  they  were  in  a  condition  to  fall 
off  spontaneously."  During  the  dark  ages  the  record  is  broken, 
and  during  the  middle  ages  only  references  are  made  to  it  in 
connection  with  gangrene.  In  this  country  it  appeared  as  early 
as  the  seventeenth  century,  at  Roxbury,  Mass. 

Samuel  Danforth,  a  graduate  of  Harvard  University,  had,  in 
1643,  twelve  children.  His  first  child  died  at  the  age  of  six 
months.  According  to  his  biographer,  John  Langdon  Sibley, 
"  the  next  three,  being  attacked  by  the  '  malady  of  bladders  in 
the  windpipe,'  in  December,  1659,  it  pleased  God  to  take  them 
all  away  at  once,  even  in  one  fortnight's  time." 

During  the  following  century  of  our  colonial  history,  occa- 
sional reference  is  made  to  its  devastations,  especially  in  Massa- 
chusetts, New  Jersey  and  New  York.  In  1735,  the  disease 
appeared  in  epidemic  form  at  Kingston,  N.  H.,  a  small  inland 
town  some  fifty  miles  eastward  of  Boston.  Dr.  Wm.  Douglas, 
at  that  time  a  prominent  physician  of  Boston,  has  given  a  most 
graphic  description  of  the  disease  and  its  ravages.  He  called 
it  "  putrid  sore  throat."     He  says : 

"  It  was  first  noticed  in  Kingston  township,  on  the  20th  of 
March,  1735.  As  this  was  an  inland  place  of  no  considerable 
trade  or  importance,  it  was  thought  (incorrectly,  perhaps)  to  be 
of  indigenous  origin,  and  not  of  foreign  importation.  The 
first  victim  was  a  child,  who  died  in  three  days;  and  about  a 
week  after  three  children  were  seized  in  another  family,  four 
miles  distant,  and  they  also  died  on  the  third  day.  It  continued 
spreading  gradually,  seizing  here  and  there  particular  families, 
with  that  degree  of  violence  that  of  the  first  forty  cases  none 
recovered.  Some  of  the  patients  died  of  a  sudden,  acute  necro- 
sis, or  mortification  ;  but  most  of  them  were  carried  off  by  a 
sympathetic  affection  of  the  fauces,  neck  or  air-passages  ;  or  by 
an  infiltration  and  tumefaction  of  the  chops,  and  forepart  of  the 
neck,  which  became  so  enlarged  and  turgid,  as  to  bring  upon  a 
level  all  parts  between  the  chin  and  sternum,  occasioning  a 
strangulation  of  the  patient  in  a  very  short  time.  After  a  few 
weeks  it  spread  from  Kingston  to  the  neighboring  townships, 
but  in  a  milder  form.  No  reason  could  be  given  for  this  greater 
malignity  in  Kingston,  except,  perhaps,  the  prevalence  of  damp 
places  near  large  ponds,  and  fresh  water,  but  sluggish  streams, 
D.  C— 22 


338  THE  DISEASES  OF  CHILDREN. 

like  in  those  localities  which  produce  the  rot  in  sheep.  There 
may  also  have  been  bad  medical  treatment.  Its  first  recog- 
nized appearance  in  Boston  was  on  the  20th  of  August,  1735, 
in  a  child  .  .  .  who  had  white  specks  in  the  throat,  and  a 
cutaneous  efflorescence.  A  few  more  .  .  .  were  seized  in 
like  manner.  Towards  the  end  of  September  it  appeared  in 
several  parts  of  the  town  of  Boston,  with  more  decided  com- 
plaint of  soreness  of  the  throat.  The  tonsils  were  swelled  and 
specked  ;  the  uvula  was  relaxed ;  there  was  slight  fever,  and  an 
erysipelas  or  scarlet-fever-like  efflorescence  on  the  neck,  chest, 
and  extremities.  The  first  alarming  case  was  in  the  beginning 
of  October,  in  a  young  man.  He  had  lately  arrived  from 
Exeter,  to  the  eastward  of  Boston,  where  his  brother  had  died 
of  the  same  illness.  His  symptoms  were  great  prostration  of 
strength,  a  single  speck  on  one  of  his  tonsils,  and  colliquative 
sweats  ...  It  increased  during  the  winter  up  to  the  second 
week  in  March,  1736;  when  it  was  at  its  height,  there  beings 
twenty-four  burials  in  all,  during  the  week  (instead  of  nine  or 
ten).  .  .  .  The  disease  was  so  much  milder  in  Boston  than 
in  some  of  the  townships  where  it  first  prevailed,  that  many 
could  not  be  persuaded  that  it  was  the  same  disorder.  .  .  . 
To  the  eastward  of  Boston,  at  times,  one  in  three  died,  in  other 
places  one  in  four,  and  in  scarce  any  towns,  less  than  one  in 
six;  whereas  in  Boston  not  above  one  in  thirty-five  succumbed." 

Belknap,  in  his  "  History  of  New  Hampshire,"  states  that  in 
that  province,  not  less  than  one  thousand  persons  died  of  the 
disease,  of  whom  nine  hundred  were  under  twenty  years  of  age. 

Dr.  Kearsley,  an  eminent  physician  of  Philadelphia,  writing 
about  the  same  time,  gives  an  affecting  account  of  its  devasta- 
tions, as  he  witnessed  them.  "  Like  most  new  diseases,"  he 
says,  "  till  their  constitution  and  nature  are  known,  it  swept  all 
before  it ;  it  baffled  every  attempt  to  stop  its  progress,  and 
seemed  by  its  dire  effects  to  be  more  like  the  drawn  sword  of 
vengeance  to  stop  the  growth  of  the  colonies  than  the  natural 
progress  of  disease.  In  the  New  England  governments  the 
stroke  was  felt  with  the  greatest  severity  ;  villages  were  almost 
depopulated,  and  parents  were  left  to  bewail  the  loss  of  their 
tender  offspring,  till  heaven,  at  last,  the  only  unerring  physi- 
cian, was  pleased  to  check  its  baneful  influence." 

From  this  early  appearance  of  the  disease  in  this  country  it 
has  never  been  entirely  absent.  A  few  isolated  towns  and 
hamlets  may  have  escaped  its  invasion,  but  in  the  larger  cities 
it  is  endemic,  and  the  rural  districts  are  rare  in  which  it  has 
not  at  some  time  been  epidemic. 

The  name  by  which  we  know  the  disease  and  which  was 
given  it  by  the  registrar-general  of  England  some  fifteen  years 


DIPHTHERIA— ETIOLOGr.  339 

ago,  is  the  only  new  feature  about  it  at  the  present  day.  Pre- 
viously it  had  been  known  by  so  many  different  appellations 
that  an  entire  page  would  be  necessary  to  enumerate  them. 
As  diphtheria  (meaning,  to  resemble  wash  leather),  it  is  now 
known  in  all  civilized  countries. 

Etiology. — Diphtheria  is  essentially  a  disease  of  childhood, 
and  most  common  before  the  age  of  puberty.  Nine-tenths  of 
its  recorded  victims  are  under  twenty  years  of  age.  In  this 
respect  it  does  not  differ,  at  the  present  day,  from  the  mortality 
ascribed  to  it  on  its  first  appearance  in  New  England.  Sex 
does  not  seem  to  influence  it. 

It  is  far  more  common  in  the  fall  and  spring — the  season  of 
colds — than  in  mid-summer  and  mid-winter.  Sudden  changes 
of  temperature  favor  it,  whether  in  summer  or  winter.  It  is 
more  prevalent  in  northern  than  in  southern  latitudes,  although 
no  place  is  known  to  be  entirely  exempt  from  it.  Other  affec- 
tions of  the  throat,  such  as  tonsilitis,  laryngitis,  pharyngitis  and 
quinsy,  are  very  commonly  associated  with  it.  It  is  apt  to 
follow  or  accompany  epidemics  of  measles  and  scarlatina. 

Its  contagiousness  is  everywhere  recognized.  And  yet  prop- 
agation by  direct  contagium  fails  to  account  for  the  vast 
majority  of  cases,  whether  occurring  in  isolation  or  in  epidemics. 
Fifty  different  epidemics  of  diphtheria,  occurring  in  various 
localities  in  England,  were  recently  investigated  with  great 
care,  and  in  only  four  could  the  outbreak  be  traced  to  direct 
contagion.  The  rest  were  all  connected,  according  to  Dr.  W. 
Gilman  Thompson,*  with  foul  cess-pools,  deficient  drainage, 
sewerage,  or  the  proximity  of  dirty  animals  and  decomposing 
organic  matter,  such  as  manure."  That  unsanitary  conditions 
favor  its  development  and  increase  its  malignancy,  goes  with- 
out saying ;  but  it  cannot,  however,  be  considered  as  essentially 
a  filth-disease.  We  have  seen  fatal  cases,  both  in  this  city  and 
neigboring  villages,  in  houses  that  were  new,  and  where  every 
sanitary  safeguard  had  been  intelligently  utilized. 

Some  twelve  years  ago  the  trustees  of  the  Newberry  estate 
erected  a  block  of  dwellings  on  the  principal  avenue  of  the 
north  division  of  Chicago.  This  avenue  was  thorough  sewered. 
The  foundations  of  the  houses  were  on  sandy  soil.  The  base- 
ment story  of  each  was  mainly  above  grade.  The  houses  them- 
selves were  of  pressed  brick,  and  no  expense  was  spared  in  their 
construction.  The  plumbing  throughout  was  the  best  that 
could  be  had.  Money,  science  and  skill  were  lavished  upon 
them  to  make  them  the  most  desirable  tenement  homes  in  the 
city. 


•  See  "American  Text-Book  of  Theory  and  Practice  of  Medicine,"  Pepper,  1893. 


340  THE  DISEASES  OF  CHILDREN. 

Among  the  first  of  the  tenants  was  a  wealthy  banker  with 
his  wife  and  one  child,  some  two  years  old.  The  latter  was  a 
robust,  healthy  boy  who  had  scarcely  suffered  a  day's  illness  in 
his  life.  But  before  the  family  had  lived  in  this  new  house  a 
year,  the  child  was  taken  ill  with  diphtheria  and  died  after  a 
week's  sickness.  For  a  month  prior  to  his  illness  he  had  not 
been  out  of  the  house,  owing  to  the  inclemency  of  the  weather. 
At  the  time  of  his  death  there  was  not  and  had  not  been  a 
case  of  diphtheria  in  the  neighborhood,  and  during  that  season 
there  was  less  than  the  usual  amount  of  the  disease  in  the  city. 
Neither  before  nor  since  has  there  been  a  serious  case  of  acute 
illness  in  the  entire  block  of  seven  houses. 

It  would  be  difficult  to  defend  the  theory  of  filth  causation 
in  a  case  like  this.  But  this  is  by  no  means  an  exceptional 
one.  The  writer  could  instance  numerous  cases  equally  in 
point,  and  doubtless  most  physicians  in  active  general  prac- 
tice could  do  the  same.  It  is  a  noteworthy  fact  in  connection 
with  the  case  just  cited  that  the  parents  of  the  child  had  pre- 
viously lost  two  children  from  the  same  disease  and  at  about 
the  same  age.  And  this  brings  us  to  consider  the  first  of  the 
causes  which  predispose  to  the  disease,  namely,  susceptibility. 
It  is  a  matter  of  common  observation  that  certain  families  are 
more  prone  than  others  to  all  forms  of  throat  disease,  includ- 
ing diphtheria.  Many  families  seem  to  possess  a  complete 
immunity  from  tonsilitis,  pharyngitis  and  throat  affections  gen- 
erally ;  while  others,  equally  well  apparently  in  other  respects, 
are  continually  under  treatment  for  some  trouble  of  the  throat. 
The  slightest  cold,  or  even  a  trifling  indigestion,  congests  the 
tonsils  or  produces  a  local  catarrh  or  inflammation.  Such 
persons  are  very  liable  to  have  diphtheria. 

Another  of  the  predisposing  causes  of  diphtheria  is  age.  As 
already  stated,  nine-tenths  of  the  mortality  from  this  disease 
occurs  in  childhood.  All  statistics  thus  far  compiled  show 
that  the  greatest  mortality  occurs  under  twelve  years  of  age. 
After  this  period  the  susceptibility  gradually  diminishes  until 
maturity  is  reached.  In  adult  life  the  disease  is  usually  much 
milder  in  form  and  markedly  less  fatal,  although  deaths  from 
diphtheria  have  been  known  to  occur  at  all  ages.  While 
rare  in  early  infancy,  Eichhorst  and  others  have  known  it  to 
be  acquired  by  the  new-born.  A  case  well  illustrating  the 
usual  non-susceptibility  of  infants  is  recorded  by  Dr.  J.  S. 
Mitchell.  "A  lady,  aged  twenty  years,  nursing  her  first  child, 
was  under  my  charge  for  a  severe  case  of  pharyngeal  diphtheria. 
The  attack  was  one  of  uncommon  severity,  approaching  the 
malignant  type.  Her  baby  nursed  regularly  throughout  the 
attack,  and  escaped  any  sign  of  the  affection." 


DIPHTHERIA— SEASON  OF  TEAR. 


341 


Season  of  Year. — Epidemics  of  diphtheria  have  been  known 
at  all  seasons  of  the  year,  but  it  is  greatly  favored  by  cold  and 
dampness.  Where  these  two  conditions  are  conjoined,  diph- 
theria is  sure  to  prevail.  The  mortality  in  this  city  from  this 
disease  during  last  year  (1892),  by  months  is  typical.  The 
mortality  for  ten  or  any  number  of  years  would  show  the  same 
relative  ratio  : 


Jan. 

Feb. 

Mar. 

Apr. 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

117 

80 

91 

62 

70 

51 

32 

49 

57 

118 

136 

151 

But  of  all  the  causes  predisposing  to  diphtheria,  the  foremost 
one  is  cold.  Children  are  proverbially  sensitive  to  atmospheric 
changes.  They  are  very  prone  to  hypertrophic  catarrhs.  Their 
tonsils  are  large  and  very  subject  to  acute  inflammation,  as  is 
also  the  whole  respiratory  tract.  The  lymphatic  system  is  very 
subject  to  disturbance  and  to  nothing  sooner  than  to  the  effects 
of  cold.  An  epidemic  of  diphtheria  occurring  at  Fort  Atkinson, 
a  small  town  in  Wisconsin,  in  the  summer  of  1885,  well  illus- 
trates not  only  how  sporadic  cases  sometimes  originate,  but 
also  how  a  sporadic  case  may  start  an  epidemic  of  indefinite 
proportions. 

In  June  of  this  year  (1885),  a  lad  of  thirteen  took  cold  from 
bathing  in  the  river,  which  runs  through  the  town,  and  the  next 
day  had  a  sore  throat,  fever  and  headache.  He  had  epistaxis 
several  times  during  the  subsequent  two  days,  but  he  was  not 
regarded  as  sick  enough  to  call  a  doctor,  and  the  exact  condi- 
tion of  his  throat  is  not  recorded.  Five  days  later,  an  infant  of 
eighteen  months  old  was  taken  sick  with  fever  and  sore  throat, 
and  speedily  developed  a  well-defined  case  of  pharyngeal  diph- 
theria, from  which  it  died  after  an  illness  of  four  days.  On  the 
day  of  its  death  a  boy,  aged  seven,  in  the  same  family,  was 
taken  sick  and  died  after  an  illness  of  three  days.  During  the 
two  weeks  subsequent  to  the  illness  of  the  first  case,  there  were 
ten  cases  in  the  immediate  neighborhood,  with  four  deaths, 
showing  a  mortality  of  forty  per  cent.  As  soon  as  the  disease 
was  recognized  as  diphtheria,  the  most  rigid  quarantine  was  es- 
tablished. The  public  school  was  closed  ;  all  social  gatherings 
were  abandoned,  and  the  infected  families  were  isolated  from 
their  neighbors.  In  this  way  the  epidemic — for  such  it  was  in 
a  small  way — was  restricted  to  a  single  row  of  houses  on  the 
one  business  street  of  the  small  town. 

Previous  to  the  outbreak  of  which  we  are  writing,  there  had 
been  but  one  single  case  of  diphtheria  known  in  the  township, 


342  THE  DISEASES  OF  CHILDREN". 

and  that  was  some  six  miles  distant  and  four  months  earlier. 
An  old  physician  who  had  practiced  there  for  over  forty  years, 
told  me  that  he  had  never  seen  a  case  of  diphtheria  in  his  life. 

Instances  by  the  score  might  be  cited  where  seemingly  an 
ordinary  cold,  in  no  way  differing  in  subjective  or  in  objective 
symptoms  from  similar  colds  taken  before,  have  in  a  given  case 
communicated  genuine  diphtheria  to  a  susceptible — and  usually 
younger — subject,  with  fatal  results.  So  often  has  this  hap- 
pened in  our  personal  experience  that  we  isolate,  so  far  as  prac- 
ticable, all  cases  of  tonsilitis  or  sore  throat  attended  with 
exudation  or  foulness  of  breath.  We  regard  this  as  absolutely 
essential  where  a  sore  throat  develops  in  an  adult  in  a  family 
where  there  are  young  children. 

It  should  be  borne  in  mind  that  adults  have  diphtheria,  as  a 
rule,  in  a  much  milder  form  than  children,  and  it  is  often  diffi- 
cult, if  not  impossible,  to  distinguish  an  innocent  and  non-con- 
tagious sore  throat  from  one  capable  of  communicating  a 
veritable  diphtheria  to  a  susceptible  child.  A  person  with  a 
sore  throat,  of  whatever  character,  no  matter  how  simple  and 
innocent  it  may  appear,  should  never  kiss  or  fondle  a  child,  if 
it  is  possible  to  avoid  it.  The  following  case,  occurring  some 
years  ago,  is  in  point.  Mr.  G.  had  just  returned  to  his  home 
from  a  trip  east,  and,  as  he  supposed,  took  cold  in  the  sleeping 
car.  The  next  day  I  was  sent  for  and  found  him  sufTering 
from  a  mild  attack  of  follicular  tonsilitis ;  at  all  events  it  had 
this  appearahce  and  nothing  more.  He  had  some  fever  and 
complained  of  headache  and  chilliness.  There  were  perhaps 
half  a  dozen  spots  or  patches  of  exudate  on  the  tonsils  which 
could  easily  be  wiped  off  with  a  pledget.  There  was  some 
dysphagia  and  the  pharynx  and  uvula  were  inflamed.  He 
made  light  of  his  illness  and  said  he  had  had  a  similar  sore 
throat  scores  of  times  before.  In  spite  of  this  I  cautioned  him 
about  caressing  his  six-year-old  son,  who  was  playing  about, 
and  of  whom  I  noticed  he  was  very  fond.  I  treated  the  case 
for  a  couple  of  days,  when  I  dismissed  him,  and  two  days 
thereafter  I  met  him  down  town  feeling  as  well  as  ever.  In 
less  than  a  week  I  was  called  to  see  this  only  child,  above  men- 
tioned, who  suddenly  developed  a  most  malignant  case  of  diph- 
theria and  he  died  after  an  illness  of  five  days. 

It  cannot  be  too  strongly  insisted  upon  that  a  catarrhal  inflam- 
mation, wherever  located,  or  however  produced,  may  become 
diphtheritic  and  pseudo-membranous.  This  is  in  harmony 
with  the  observation  made  by  Billroth,  that,  "Catarrhal  con- 
junctivitis, which  is  so  very  common,  may  become  diphtheritic." 

In  a  recent  lecture  delivered  at  the  Sanitary  Institute  in 
London,  Dr.  Thorne  Thorne,  C.B.,  F.R.S.,  a  medical  officer  of 


DIPHTHERIA— SEASON  OF  YEAR.  343 

the  Local  Government  Board  of  England,  expresses  himself  as 
fully  convinced  that  diphtheria  is  disseminated  through  schools 
by  failure  to  isolate  or  exclude  pupils  suffering  with  an  ordinary 
or  simple  sore  throat.  He  says  :  "  Where  sore  throat  ends  and 
diphtheria  begins,  I  cannot  say  ;  but  no  child  who  is  suffering 
from  any  form  of  sore  throat  should  be  allowed  at  school,  nor 
even  any  one  from  the  house  in  which  that  child  resides."  He 
gives  many  statistics  to  show  that  in  outbreaks  of  diphtheria 
in  towns  and  hamlets  throughout  England,  school  children  are 
not  only  first  affected,  but  as  a  rule  those  children  who  do  not 
attend  school  are  for  the  most  part  exempt ;  notwithstanding 
a  considerable  epidemic  may  be  prevailing.  He  further  says  : 
*'  During  the  cold  weather  the  people  all  get  sore  throat,  and  if 
you  look  into  their  throats,  you  will  always  find  traces  of  ulcer- 
ation, due  to  past  attacks  of  inflammation  of  the  tonsils.  The 
sore  throat — an  ordinary  sore  throat,  so  far — is  passed  from  one 
to  another  (for  all  forms  of  sore  throat  are  apparently  infec- 
tious), and  by  and  by — as  I  have  observed  over  and  over  again 
— it  gets  worse  and  worse,  until  it  culminates  in  an  outbreak  of 
diphtheria.  The  explanation  that  has  occurred  to  me  in  respect 
of  these  circumstances,  is  a  progressive  increase  in  the  infec- 
tiousness of  the  poison  which  produces  diphtheria." 

Some  years  ago  (1884),  I  read  a  paper  before  the  Illinois 
Homeopathic  Medical  Association  on  "  The  Cumulative  Po- 
tency of  the  Diphtheritic  Contagium."  In  this  paper  I  instanced 
twenty-seven  families  in  which  there  had  been  multiple  cases 
of  diphtheria,  and  in  nearly  all  of  which  the  second  or  subse- 
quent case  was  more  severe  than  the  first.  I  cited  numerous 
instances  in  which  the  primary  case  was  so  mild  as  to  be,  in 
many  of  them,  uncertain  of  diagnosis  ;  but  the  second  case  was 
severe,  critical  or  fatal.  My  experience  during  the  past  ten 
years  has  only  served  to  confirm  this  observation,  and  empha- 
sizes the  importance  of  exercising  the  most  rigid  quarantine  of 
every  case  of  diphtheria  or  even  of  a  sore  throat,  that  is  at  all 
suspicious  of  being  infectious  in  its  nature.  This  question  has 
a  most  practical  bearing.  Quite  recently  the  press  of  this  city 
strongly  urged  the  establishment  of  a  diphtheria  hospital, 
where  children  affected  with  this  disease  could  be  taken  and 
cared  for,  and  where  it  was  supposed  they  would  be  under 
better  auspices  than  at  their  homes.  Such  an  establishment 
would  only  add  to  the  number  of  fatalities  and  do  infinitely 
more  harm  than  good.  The  more  contagious  diseases  are 
aggregated,  the  greater  the  per  cent,  of  mortalities,  and  with 
diphtheria  this  is  preeminently  true.  Isolation  of  the  first  case 
and  a  quarantine  more  or  less  rigid  of  all  forms  of  sore  throat, 
is  the  only  safe  and  scientific  procedure. 


344  THE  DISEASES  OF  CHILDREN. 

Contagiunt. — While  tender  age  is  a  predisposing  factor,  and 
cold  is  frequently  an  exciting  cause  of  diphtheria,  many  cases 
originate  from  a  contagium  emanating  from  some  previous 
case.  That  the  disease  is  distinctly  and  markedly  contagious,, 
no  longer  admits  of  doubt ;  but  we  cannot  agree  with  Jacobi, 
J.  Lewis  Smith  and  others,  who  assert  that  the  contagium  ex- 
tends but  a  few  feet  beyond  the  person  infected.  Some  few 
years  ago  we  attended  the  aunt  of  a  two-year-old  child,  with  a 
moderately  severe  attack  of  diphtheria.  During  the  aunt's  ill- 
ness the  child  crept  out  of  its  nursery  on  the  lower  floor, 
climbed  the  stairs,  and  peeped  through  the  half-open  door  of 
the  sick-room.  It  was  during  one  of  my  professional  visits,  and 
as  soon  as  the  child's  presence  was  noticed,  it  was  hurried  back 
to  its  own  room.  He  was  not  in  the  hallway  over  half  a  min- 
ute, and  did  not  enter  the  chamber.  In  spite  of  this,  he  took 
the  disease  after  an  incubative  period  of  two  days,  and  died  ten 
days  later.  As  to  the  nature  of  the  poison  which  gives  to 
diphtheria  its  contagious  element,  authorities  differ  greatly. 
To  those  who  accept  the  germ  theory  of  contagion,  it  would 
seem  almost  sacrilegious  to  even  question  the  part  which  mi- 
crobes play  in  this  disease. 

Ever  since  Buhl  first  discovered  microbes  in  the  diphtheritic 
deposit,  and  Hueter  and  Oertel  simultaneously  detected  them 
in  the  subjacent  mucous  membrane  and  in  the  blood  of  those 
infected  with  the  disease,  no  effort  has  been  spared  to  identify 
the  particular  bacillus  on  which  to  fix  the  onus  of  responsibility. 
After  numerous  failures  to  find  a  bacillus  in  diphtheria  that 
could  not  be  found  elsewhere,  Klebs,  in  1883,  and  Loffler,  of 
Greifswald,  in  1884,  found  one  in  the  exudate  and  on  the  adja- 
cent mucous  membrane,  that  so  far  seems  to  meet  all  the 
necessities  of  the  case ;  and  the  particular  microbe  which  the 
germ  theorists,  or  most  of  them,  now  consider  to  cause  diph- 
theria, is  known  as  the  Klebs-Loffler  bacillus.  The  causative 
relation  of  the  germ  to  diphtheria  is  disputed  even  by  some 
eminent  bacteriologists  ;  while  there  are  many,  ourselves  among^ 
the  number,  who  are  exceedingly  skeptical  about  germs  causing 
this,  or  any  of  the  other  contagious  diseases.  For  the  sake  of 
those  who  are  pursuing  the  study  of  the  germ  theory,  and  in- 
vestigating its  merits,  we  give  the  following  description  of  the 
bacillus  diphtheria,  as  found  in  Pepper's  "American  Text- 
Book  of  the  Theory  and  Practice  of  Medicine,"  page  374. 

"  The  diphtheria  bacillus  is  a  little  shorter  than  the  tubercle 
bacillus,  but  is  much  broader  and  has  thickened  or  clubbed 
extremities.  It  is  sometimes  curved,  sometimes  spindle- 
shaped.  ...  It  is  capable  of  deep  staining,  and  then 
presents  a  segmented  granular  appearance.     The  bacilli  often 


DIPHTHERIA— CONTAGIUM.  345 

occur  in  groups.  On  the  outer  surface  of  the  false  membrane 
several  varieties  of  bacilli,  including  the  Klebs-Lofifler  germ, 
are  found.  Immediately  below,  is  a  layer  containing  many 
cells  and  but  little  fibrin,  and  here,  again,  the  bacilli  in  groups 
are  apparent.  Finally,  in  the  deepest  fibrin  layer,  which  rests 
upon  the  mucous  membrane,  no  Klebs-Loffler  bacilli  are 
present.  (Welch,  Abbott.)  The  bacillus  diphtheria  grows 
readily  in  a  variety  of  culture  media.  It  is  killed  at  58°  C.  in 
ten  minutes.     (Welch,  Abbott.)" 

The  writer  from  whom  this  description  is  taken,  Dr.  W.  Gil- 
man  Thompson,  says  that  the  bacillus,  "  comes  in  contact  with 
the  faucial,  or  other  mucous  surface,  or  the  abraded  skin,  and 
propagates  there ;  but  it  does  not  penetrate  deeply  into  the 
mucous  membrane,  nor  is  it  taken  up  by  the  blood-vessels  or 
lypmhatics.  The  bacilli,  therefore,  do  not  invade  the  entire 
body,  but  remain  at  the  site  of  the  local  lesion,  imbedded  in  the 
pseudo-membrane^     (The  italics  are  ours.) 

The  position  taken  by  the  early  bacteriologists,  that  micro- 
organisms were  directly  implicated  in  the  causation  of  disease, 
was  soon  found  to  be  untenable.  Hiller  found  microbes  in  the 
cadavers  of  those  who  had  not  died  of  septic  disease,  and  many 
acute  observers  failed  to  find  them  except  in  close  proximity 
to  the  original  seat  of  infection,  although  there  was,  as  in  all 
severe  cases  of  diphtheria,  profound  constitutional  disturbances. 
Oertel  propounded  the  theory  that,  while  the  inoculation  was, 
by  the  action  of  the  microbes,  causing  a  local  disease,  this  local 
disease  extended  through  the  organism  and  became  general  by 
means  of  the  absorbents  and  lymphatics.  Narsiloff,  Eberth, 
Klebs,  and  others,  by  their  experiments  and  exhaustive  re- 
searches, endeavor  to  sustain  this  view,  as  do  also  Obermeir, 
Pasteur  and  Koch.  On  the  other  hand,  Panum,  Bergman, 
Schmeideberg  and  others  have  isolated  poisons  of  marked 
septic  power,  which  contained  no  bacteria  whatsoever.  Ram- 
itsch  and  many  others  have  demonstrated  that  septic  infection 
is  not  dependent  on  the  existence  of  bacteria.  It  has  been 
shown  by  Devein  and  others  that  an  infinitely  small  amount 
of  chemical  poison,  entirely  free  from  bacteria,  can  kill  quickly. 

It  has  been  found  by  careful  experiments  by  Hiller,  Webber 
and  Hemmer,  that  the  injection  of  isolated  bacteria  in  large 
numbers  or  colonies,  into  the  sub-cutaneous  cellular  tissue  of 
dogs  and  rabbits,  produced  a  slight  local  swelling,  but  neither 
abscess  nor  fever.  Hiller  injected  these  into  his  own  subcu- 
taneous cellular  tissue,  without  producing  any  other  effect 
than  a  slight  edema.  After  these  observations  had  been 
repeated  and  verified  by  numerous  observers,  the  micro-or- 
ganisms  were  carefully   classified  into  disease-producing  and 


346  THE  DISEASES  OF  CHILDREN. 

non-producing  bacteria ;  for  it  was  clearly  demonstrated  that 
many  forms  of  bacteria  were  perfectly  innocuous. 

It  was  further  found  that  even  the  septic  or  disease-produc- 
ing bacteria  were  only  the  indirect  producers  of  mischief.  This 
indirect  production  of  disease  phenomena,  was  explained  as 
due  to  the  agency  of  "a  specific  product  of  the  specific  microbe, 
elaborated  in  the  process  of  its  growth  or  decay,  the  '  specific 
product '  being  in  the  nature  of  a  peculiar  poison  possessing 
not  only  specific  physiological  action,"  but  also  having  peculiar 
chemical  properties  and  constitutions,  which  ally  them  more  or 
less  closely  to  certain  well-known  poisonous  vegetable  alkaloids. 
These  chemical  bodies  have  received  the  name  of  ptomaines  or 
toxines. 

It  is  claimed  that  each  infectious  disease,  diphtheria  included, 
not  only  has  its  specific  bacillus,  but  a  specific  ptomaine  or 
toxine — the  product  thereof — which  is  the  propagating  con- 
tagium  of  the  particular  disease ;  and  it  is  further  claimed  that 
by  inoculating  a  person  with  the  special  ptomaine  of  that  dis- 
ease, such  person  secures  immunity  from  the  effects  of  subse- 
quent exposure.  Many  attempts  have  been  made  to  guard 
cattle  and  smaller  domestic  animals  from  destruction  by  infec- 
tious or  contagious  diseases  by  such  inoculation  ;  but  such 
experiments  have  been  thus  far  only  partially  successful,  and 
the  results  are  still  in  doubt. 

The  theory  is  fascinating.  In  some  instances  the  protection 
afforded  by  inoculation,  notably  those  of  Pasteur  in  the  char- 
bon  of  sheep,  is  almost  conclusive  proof  of  the  truth  of  the 
premises  ;  but  no  sooner  does  one  experimenter  report  successes 
than  others,  equally  trustworthy  and  skillful,  report  an  equal 
number  of  signal  failures.  It  may  be  true,  as  an  enthusiastic 
writer  of  recent  date  says:  "  The  immunity  acquired  by  surviv- 
ing a  natural  attack,  or  an  artificial  production  of  the  disease,  is 
secured  by  the  action  in  the  tissues  of  the  specific  microbe 
through  its  ptomaines ;  and  this  action  is  probably  due  both  to 
the  restraining  effect  of  the  ptomaine  itself  upon  the  develop- 
ment of  the  specific  bacterium,  which  generates  it  in  a  manner 
quite  analogous  to  the  effect  of  alcohol  generated  in  the  pro- 
cess of  fermentation,  in  arresting  at  a  certain  stage  the  growth 
of  the  microbe  which  produces  it,  and  to  the  establishment  of 
a  tolerance  by  the  animal  organism,  for  the  poisonous  alkaloid. 
When  the  properties  of  the  various  specific  ptomaines  shall 
become  thoroughly  known  and  well  demonstrated,  the  success- 
ful and  safe  control  of  epidemic  diseases  will  probably  become 
a  matter  of  certainty."  * 


*  Keating,  vol.  i,  page  190. 


DIPH  THERIA — C  ON  TAG  I UM.  347 

At  the  present  writing  this  sounds  Utopian,  and  at  best  it 
will  be  a  long  time  before  the  human  family  will,  by  means  of 
a  series  of  inoculations,  be  rendered  exempt  from  the  conta- 
gious and  infectious  foes  that  hamper  its  usefulness  and  threaten 
its  life.  The  time  has  not  yet  come  when  the  germ  theory, 
even  as  modified  by  its  latest  and  most  conservative  exponents, 
can  be  accepted  as  conclusive.  There  are  many  facts  which  go 
to  show  that  bacteria  are  merely  accidental  or  incidental  factors 
of  secondary  influence,  when  compared  with  other  factors  yet 
undiscovered  and  hence  unknown. 

Some  years  ago  Wood  and  Formad,  under  the  direction  of 
the  United  States  Government,  made  some  original  investiga- 
tions, in  order  to  ascertain  the  precise  role  played  by  bacteria 
in  the  causation  of  diphtheria.  They  made  thirty-two  experi- 
ments. Diphtheritic  matter  was  injected  subcutaneously  and 
in  the  mucous  membrane  of  the  mouth.  Only  six  animals 
died,  and  of  these  one  case  alone  presented  exudations  indicat- 
ing that  death  might  have  occurred  from  diphtheria.  The  in- 
ternal organs  of  the  animals  were  tuberculous.  The  results  of 
the  experiments  of  Burden  Sanderson,  who  produced  tubercles 
in  guinea  pigs  by  inserting  cotton  threads  in  the  skin,  were 
further  confirmed  by  Wood  and  Formad,  in  their  experiments. 
In  Wood's  experiments,  which  consisted  in  introducing  small 
masses  of  innocuous  foreign  substance  under  the  skin,  tubercu- 
losis was  found  in  five  after  death. 

Dr.  J.  S.  Mitchell,  in  his  admirable  article  on  diphtheria  in 
Arndt's  "System  of  Medicine,"  says  in  this  connection: 

"  Experiments  have  demonstrated  that  ammonia,  cantharides, 
and  other  chemicals,  may  induce  the  growth  of  a  pseudo-mem- 
brane, when  introduced  into  the  system.  It  has  been  shown 
that  bryonia  has  this  effect.  M.  Currie  {British  Journal  of 
Homeopathy,  vol.  19,  p.  455),  made  the  following  experiment: 
He  gave  a  rabbit  increasing  doses  daily  of  the  tincture  of  bry- 
onia, until  he  came  to  250  drops,  when  he  developed  a  firm 
pseudo-membrane  extending  from  the  larynx  to  the  bronchioles 
of  the  third  degree.  It  would,  therefore,  seem  that  diphtheritic 
matter,  artificially  introduced  within  the  body,  is  not  so  likely 
to  produce  the  characteristic  lesion  of  diphtheria  as  some  other 
substances.  Experiments  were  performed  with  organic  matter 
to  see  if  products  of  disease  other  than  diphtheritic  exudations 
would  give  the  pseudo-membrane.  The  material  was  pus  in 
four  instances.  Two  of  these  gave  false  membrane,  so  this 
result  was  better  than  where  diphtheritic  matter  was  used. 
The  conclusion  of  Wood  and  Formad  is :  The  contagious  ma- 
terial of  diphtheria  is  really  of  the  nature  of  a  septic  poison, 
which  is  locally  very  irritating  to  the  mucous  membrane,  so 


348  THE  DISEASES  OF  CHILDREN. 

that,  when  brought  in  contact  with  that  of  the  mouth  and 
nose,  it  produces  an  intense  inflammation  without  absorption 
by  a  local  process.  While  absorption  is  not  necessary  for  the 
production  of  the  angina,  it  is  very  probable  that  the  poison 
may  act  locally  after  absorption  by  being  carried  in  the  blood  to 
the  mucous  membrane.  Further,  under  this  theory  it  is  pos- 
sible that  the  poison  of  diphtheria  may  cause  an  angina  which 
will  remain  a  purely  local  disorder,  no  absorption  occurring  ; 
or  a  simple  local  tracheitis,  produced  by  an  exposure  to  cold  or 
some  non-specific  cause,  may  produce  the  septic  material,  when 
absorption  will  cause  blood-poisoning,  the  case  ending  in 
adynamic  diphtheria. 

"  Some  such  explanation  as  this  here  offered  seems  to  recon- 
cile the  antagonistic  opinions  concerning  the  value  of  local 
treatment  in  diphtheria,  because  it  is  plain  that  the  value  of 
such  treatment  must  largely  depend  on  whether  the  angina  has, 
or  has  not,  been  produced  by  absorption.  At  present  it  seems 
altogether  improbable  that  bacteria  have  any  direct  action  in 
diphtheria — that  is,  that  they  enter  the  system  as  bacteria,  and 
develop  as  such  in  the  system,  and  cause  the  symptoms.  It  is, 
however,  probable  that  they  may  act  upon  the  exudation  of 
the  trachea,  as  the  yeast-plant  acts  upon  sugar,  causing  the  pro- 
duction of  a  septic  poison  which  differs  from  that  of  ordinary 
putrefaction,  and  bears  such  relations  to  the  system  as  to  cause 
the  systemic  symptoms  of  diphtheria  when  absorbed.  Now, 
these  bacteria  may  always  be  in  the  air,  but  not  in  sufificient 
quantities  to  cause  tracheitis,  but  enough,  when  lodged  in  the 
membrane,  to  set  up  the  peculiar  fermentation  ;  whilst  during 
an  epidemic  they  may  be  sufficiently  numerous  to  excite 
inflammation  in  a  previously  healthy  throat.  The  investiga- 
tions and  experiments  of  Wood  and  Formad  are  the  most 
complete  and  conclusive  on  this  subject  which  we  have  yet 
had,  and  they  confirm  the  view,  long  held  by  some,  that  the 
bacteria  may  fall  in  showers  upon  the  unprepared  mucous 
membrane,  and  not  induce  diphtheria,  and  that  the  real  etio- 
logical factor,  or  factors,  which  render  it  susceptible  to  their 
action,  are  yet  unknown." 

To  sum  up  the  net  results  of  the  tireless  investigations  and 
experiments  that  have  been  carried  on  in  this  connection 
during  the  past  twenty-five  years,  both  in  this  country  and  in 
Europe,  by  the  ablest  scientists  in  the  world,  it  can  only  be 
said  that  the  cause,  the  essential  factor  in  the  production  of 
diphtheria — the  one-element  without  which  the  disease  is  not — 
is  2i poison;  a  fact  that  was  known  a  thousand  years  before  the 
Christian  era.  Whence  it  originates,  whether  from  within  or 
without :  whether  it  be  a  product  of  disturbed  metabolism — a 


DIPHTHERIA— VITALITY  OF  POISON.  349 

sudden  vitiation  of  normal  secretions ;  or  whether  it  be  from 
the  inhibition  of  poisonous  emanations  from  polluted  soil,  we 
are  just  as  much  in  the  dark  as  was  Hippocrates  or  Galen. 
It  is  helpful,  nevertheless,  to  call  it  a  "poison,"  and  to  treat  it 
as  such. 

We  are  not  called  upon  to  regard  a  drug  as  valuable  or  val- 
ueless, according  to  its  real  or  supposed  power  to  kill  germs. 
We  are  left  free  to  revert  back  to  such  empirical  treatment  as 
clinical  experience  has  indorsed,  and  to  pursue  our  investiga- 
tions and  researches  in  the  field  of  therapeutics,  solely  intent  on 
finding  that  which  will  reach  and  wipe  out  the  symptoms  of 
disease,  regardless  of  germs  or  their  hypothetical  ptomaines. 

Vitality  of  the  Poison. — However  we  may  regard  the  nature 
of  the  contagious  principle,  or  element,  its  power  for  mischief 
is  of  very  long  duration.  Like  the  infection  of  scarlatina,  which 
it  strongly  resembles  in  many  other  respects,  it  may  retain  its 
poisonous  properties  for  months  or  even  years.  In  1888,  we 
saw  a  case  of  diphtheria  in  consultation  with  Dr.  C.  E.  Williams, 
of  this  city.  It  was  a  malignant  case,  and  was  practically 
hopeless  at  the  time  we  saw  it.  A  year  or  more  afterward  we 
were  called  to  see  an  infant  of  an  old  client  who  had  been  long 
absent  from  the  city,  and  who,  on  his  return,  had  rented  this 
same  house.  After  the  death  of  the  child  before  alluded  to, 
the  house  had  been  thoroughly  disinfected — as  was  supposed — 
the  inner  walls  had  been  newly  papered,  the  woodwork  re- 
painted and  the  floors  throughout  newly  carpeted.  My  friends 
were  ignorant  that  the  house  had  previously  harbored  an  infec- 
tious disease.  Their  occupancy  had  scarcely  been  a  full  week, 
when  the  infant,  a  year  old,  was  taken  ill  with  diphtheria,  and 
"died  some  nine  days  later.  The  only  surviving  child,  a  girl  of 
ten  years,  was  sent  to  a  neighbor's  as  soon  as  the  nature  of  the 
disease  was  recognized ;  but  she  developed  malignant  diph- 
theria the  following  morning,  and  she  also  died  after  a  brief 
illness. 

In  culture  experiments,  the  poison  has  been  known  to  retain 
its  virulence  for  sixteen  months.  According  to  Sevestre,  in  a 
Normandy  village,  twenty-three  years  after  an  epidemic  of 
diphtheria,  some  of  the  bodies  of  those  who  died  of  the  disease 
were  exhumed  and  an  epidemic  at  once  broke  out,  first  among 
those  who  opened  the  graves,  and  extended  to  others.  Un- 
doubtedly the  diphtheric  poison  has  great  tenacity  of  life  and 
too  great  precautions  cannot  be  taken  to  prevent  its  further 
spread. 

Varieties. — Between  the  mildest  and  the  malignant  form  of 
diphtheria,  as  it  is  clinically  encountered,  there  is  a  vast  differ- 
ence.    In  concluding  a  report  of  a  recent  investigation  of  this 


350  THE  DISEASES  OF  CHILDREN. 

question,  Abbott  says :  "  From  these  observations  we  feel  jus- 
tified in  agreeing  with  the  opinion  that  has  been  advanced  by 
other  observers,  particularly  Hoffmann  and  Rowe  and  Yersin, 
that  under  varying  conditions  the  virulence  of  the  true  diph- 
theria bacillus  may  be  observed  to  fluctuate  in  the  degree  of 
its  intensity — at  one  time  possessing  the  property  in  a  high 
degree,  at  another,  presenting  a  decided  attenuation,  and  not 
unfrequently  a  complete  absence  of  pathogenic  power."  If,  in 
the  above  extract,  we  substitute  for  "  bacillus,"  contagium,  or 
"  poison,"  we  shall  understand  how  age,  susceptibility,  consti- 
tution, environments,  attenuation  or  concentration  of  virus,  may 
so  modify  the  disease  in  a  given  subject  as  to  render  it  scarcely 
distinguishable  from  some  milder  affection,  or  render  it  so  ma- 
lignant as  to  be  fatal  within  a  few  hours. 

By  some  authorities  the  disease  is  classified  according  to  the 
particular  region  principally  affected.  Thus,  these  authorities 
make  a  distinct  class  of  pharyngeal,  laryngeal,  and  naso-pharyn- 
geal  diphtheria.  But  there  is  little  practical  benefit  to  be 
derived  from  this  multiplication  of  terms.  Whether  the  disease 
be  mild  or  malignant,  it  is  liable  to  invade  primarily  or  seconda- 
rily any  of  the  mucous  orifices ;  and  it  may  even  invade  the 
system  through  an  abrasion  of  the  skin  or  an  open  wound, 
wherever  situated.  The  most  common  seat  of  the  local  lesion, 
however,  is  on  the  tonsils,  from  whence  it  is  prone  to  extend 
into  the  pharynx,  onto  the  uvula,  and  the  palate,  and  in  a  cer- 
tain proportion  of  cases  it  begins  in  or  extends  to  the  larynx, 
when  its  dangers  are  always  greatly  increased. 

Immunity. — There  is  much  difference  of  opinion  among  ob- 
servers as  to  whether  one  attack  of  diphtheria  does  or  does  not 
confer  immunity  from  future  danger.  The  majority  of  accessi- 
ble authors  is  decidedly  in  favor  of  the  non-protection  side 
of  the  question.  Our  own  opinion  is  that  in  this  case,  the 
majority  is  wrong.  In  nearly  thirty  years  of  continuous 
general  practice,  we  have  never  seen  diphtheria  repeated  in 
the  same  subject.  Having  had  the  disease  ourselves  in  a  mild 
form  some  seventeen  years  ago,  we  have  since  then  attended 
scores  of  cases,  of  all  degrees  of  severity,  without  a  second 
infection. 

In  exceptional  cases  both  scarlatina  and  variola  are  repeated 
in  the  same  subject,  and  the  same  is  true  of  rubeola.  The  ex- 
ceptions, however,  only  prove  the  rule.  We  do  not  scruple  to 
assure  our  patients,  who  have  once  been  attacked  by  a  distinct 
diphtheria,  that  they  need  have  no  fear  of  a  recurrence. 

While  diphtheria  is  indubitably  contagious,  its  infective  prop- 
erties are  considerably  less  than  those  of  scarlet  fever.  It  is 
not,  as  a  rule,  propagated  by  means  of  fomites,  as  is  the  latter 


DIPHTHERIA— PROGNOSIS.  351 

affection.  We  have  never  known  a  case  of  diphtheria  resulting 
from  a  physician  carrying  the  infection  in  his  clothing,  although 
it  frequently  happens  that  he  is  compelled  to  go  from  an  in- 
fected house  to  one  where  there  are  unprotected  children. 

There  is  no  adequate  explanation  for  this,  except  that  the 
contagium  is  quickly  dissipated  in  the  outer  air  or  speedily  per- 
ishes except  in  confined  areas.  Dr.  Mitchell's  theory  of  account- 
ing for  this  fact  is  at  least  ingenious.  He  says  :  "A  reasonable 
theory  would  seem  to  be  that  the  physician  combines  in  his 
person  so  many  of  the  specific  causes  of  different  diseases  as 
not  to  allow  any  one  to  be  signally  operative." 

Incubation. — So  many  circumstances  interfere  with  observa- 
tions on  this  score,  and  so  difficult  is  it  usually  to  trace  the  dis- 
ease to  its  distinct  source,  that  no  certain  period  of  incubation 
can  be  given.  Doubtless  it  differs  in  different  cases.  In  a  sus- 
ceptible subject  it  may  be  but  a  few  hours,  while  in  one  less 
susceptible  it  may  be  many  days.  From  our  own  and  the  ob- 
servation of  others,  the  period  may  be  said  to  be  from  two  to 
seven  days — in  some  cases  longer.  We  have  several  times 
noticed  the  invasion  to  be  two  days  after  known  exposure,  and 
in  one  case  it  was  four  days. 

Duration. — Diphtheria  is  a  disease  of  indefinite  duration. 
The  average  case  lasts  from  ten  days  to  a  fortnight.  Very 
mild  cases  may  terminate  in  a  week,  while  those  which  are  more 
severe,  may  last  three  or  four  weeks.  Cases  are  on  record 
where  complete  recovery  did  not  take  place  until  after  several 
months.  The  sequelae,  such  as  paralysis  and  albuminuria,  may 
last  indefinitely,  although  as  a  rule  the  duration  is  not  over  a 
few  weeks. 

Prognosis. — This  should  always  be  guarded.  The  disease  is 
full  of  pitfalls  and  disappointments.  The  prognosis  varies  in 
different  epidemics.  So  long  as  the  heart's  action  is  strong  and 
the  digestive  powers  remain  good,  there  is  every  ground  for 
hope.  Under  such  circumstances,  and  in  the  absence  of  exten- 
sion of  the  membrane  to  the  nose  or  larynx,  the  prognosis  is 
favorable.  If  the  patient  is  seen  early  and  is  of  good  constitu- 
tion, proper  treatment  ought  to  afford  a  good  chance  for  recov- 
ery. When  diphtheria  complicates  a  case  of  measles  or  scarlatina, 
which  has  already  sapped  the  vitality  of  the  child,  the  prognosis 
is  less  favorable.  The  younger  the  child,  the  more  apt  the 
disease  is  to  prove  fatal.  The  amount  of  pseudo-membrane  is 
not  usually  to  be  depended  upon  as  a  criterion  for  estimating 
the  gravity  of  the  attack.  There  may  be  but  a  few  traces  of  it 
in  the  fauces,  and  yet  a  great  amount  of  systemic  poisoning. 
On  the  other  hand,  the  fauces  may  be  thickly  covered  with  a 
dense  membrane  and  yet  recovery  take  place. 


352  THE  DISEASES  OF  CHILDREN. 

Mortality. — It  is  very  difficult  to  correctly  estimate  the  mor- 
tality from  this  disease.  Many  physicians  in  good  professional 
standing  are  densely  ignorant  of  its  proper  diagnosis.  They 
will  tell  you  that  they  have  treated  fifty  or  a  hundred 
cases  of  diphtheria  without  losing  a  single  case  ;  while  all  au- 
thorities place  the  mortality  at  from  40  to  75  per  cent.  With 
900  cases  recently  treated  in  Strasburg,  the  mortality  was  46.7 
per  cent.  In  New  York  City,  according  to  Thompsen,  it  aver- 
ages above  47  per  cent,  and  may  reach  55  per  cent.  Over  50 
per  cent,  of  deaths  from  diphtheria  occur  in  children  under  five 
years  of  age,  and  about  75  per  cent,  occur  among  those  under 
ten  years  of  age. 

These  figures  are  taken  from  general  current  statistics.  We 
have  no  exact  data  as  to  the  relative  mortality  under  homeo- 
pathic treatment  ;  and  it  would  be  unfair  to  assume  superior 
results  without  supporting  data. 

The  employment,  however,  of  such  heroic  measures,  both 
topically  and  internally,  as  has  characterized  old-school  methods, 
based  upon  the  belief  that  the  most  powerful  germicides  were 
alone  equal  to  combat  the  hordes  of  micro-organisms  found  in 
and  about  the  pseudo-membranes,  could  not  do  otherwise  than 
render  mild  cases  severe  ones,  and  take  from  many  the  chance 
of  recovery  which  would  have  been  theirs  had  nature  been  left 
alone  to  exercise  her  restorative  powers. 

Are  True  Croup  and  Diphtheria  Identical? — Many  of  the 
older  writers,  and  indeed  some  recent  and  most  reputable  au- 
thorities, such  as  Bretonneau,  Morell  McKenzie,  and  Sir  Wil- 
liam Jenner,  in  Europe,  and  Jacobi  and  Loomis  in  this  country, 
have  expressed  themselves  as  believing  in  the  essential  identity 
of  diphtheria  and  cynanche  trachealis,  or  true  croup.  Others, 
and  among  them  we  must  emphatically  place  ourselves,  observe 
so  many  vital  points  of  difference  between  the  two  diseases 
that  we  are  constrained  to  consider  them  as  distinct  and  sepa- 
rate affections.  Diphtheria  is  a  general  or  constitutional 
disease  of  markedly  asthenic  character,  while  true  or  membra- 
nous croup,  is  a  local  affection  of  sthenic  type.  There  is  always 
a  more  or  less  pungent  odor  about  diphtheria  which  is  absent 
in  croup.  Diphtheria,  starting  in  the  larynx,  seldom  or  never 
progresses  upward.  True  croup  often  does.  The  importance 
of  the  question  is  most  certainly  one  which  can  hardly  be  over- 
estimated, for  it  has  a  bearing  not  only  on  the  therapeutic 
management,  but  upon  the  prognosis  and  the  prophylaxis  as 
well.  In  order  to  assist  the  reader  in  differentiating  the  one 
from  the  other,  and  the  more  clearly  to  contrast  their  salient 
features,  we  place  their  more  prominent  symptoms  side  by  side 
in  the  following  table  of  comparison. 


DIPHTHERIA— PA  THOL  OG  T. 


353 


Distinctive  Diagnosis  Between  Membranous  and  Diphtheritic 
Croup. — The  Pacific  Medical  and  Surgical  Journal  presents  the 
following — as  abbreviated,  with  emendations,  from  Dr.  Hugo 
Engel's  statement  in  the  Philadelphia  Medical  and  Surgical 
Reporter:  '^Q^^-J^J^-^^-^-^^  (^  "'-'^X^ 


Membranous  Croup. 

Cause,  exposure  to  cold. 

Period  of  incubation,  none. 

A  local  history  at  beginning. 

Constitutional  symptoms  secondary. 

Begins  in  larynx. 

May  extend  upwards. 

Affects  children  only. 

Begins  suddenly  in  the  night. 

Loss  of  strength  near  the  end. 

Death  from  apnea. 

No  complications. 

Albuminuria  only  towards  the  last. 

Glands  not  enlarged. 

Never  contagious. 

No  sequelae. 

Convalescence  rapid. 

Membrane  soluble  in  potash  solution. 

Hardened  by  sulphuric  acid. 


Laryngeal  Diphtheria. 

Cause,  specific  poisoning. 

One  to  five  days  or  more. 

Constitutional. 

Primary. 

In  pharynx. 

Extends  downwards. 

Adults  also. 

Prodromes  for  some  days. 

From  the  beginning. 

Often  from  ataxia. 

Nose  and  heart  often  implicated. 

From  the  outset. 

Always  enlarged. 

Decidedly  contagious. 

Paralysis  often. 

Slow  and  tedious. 

Soluble  in  sulphuric  acid. 

Hardened  by  potash  solution. 


Pathology, — It  has  always  been  a  mooted  point  as  to  the 
relation  which  the  pseudo-membrane  bears  to  the  constitutional 
disorder.  By  many  it  is  claimed  that  in  the  beginning  diph- 
theria is  always  a  local  disease,  and  that  if  seen  in  its  earliest 
stages,  the  poison  may  be  neutralized  by  judicious  treatment, 
and  constitutional  infection  in  this  way  prevented.  This  was 
the  opinion  of  the  late  Prof.  W.  F.  Knoll,  who  strongly  advo- 
cated the  topical  use  of  strong  carbolic  acid.  Except  in  rare 
instances,  the  first  perceptible  lesion  is  in  the  fauces,  and  on  the 
tonsils,  and  symptoms  of  general  infection  are  usually  not 
observed  until  some  hours — or  days  in  some  cases — after  the 
pseudo-membrane  has  shown  itself.  But  fatal  cases  of  diph- 
theria have  been  recorded  in  which  there  was  no  deposit,  either 
on  the  tonsils  or  anywhere  in  the  throat.  Thus,  M.  Trousseau 
observed  cases  of  diphtheria  in  a  village  in  the  neighborhood 
of  Orleans,  where  diphtheria  prevailed,  presenting  in  some 
cases  its  ordinary  features ;  manifesting  itself  in  others  by 
deposits  of  false  membrane  on  the  vulva,  or  the  mammae,  on 
blistered  surfaces  or  on  ulcers,  and  "  proving  fatal  in  some  cases 
without  the  throat  being  at  all  involved  in  the  disease."  The 
great  depression  of  vital  powers,  which  is  so  characteristic  of 
the  disease,  sometimes  manifests  itself  even  before  the  throat 
symptoms,  and  in  malignant  cases  death  has  been  known  to 
D.  C— 23 


354  THE  DISEASES  OF  CHILDREN. 

take  place  before  the  real  nature  of  the  affection  was  recognized 
— the  cause  of  death  being  only  revealed  post-mortem. 

The  albuminuria  which  usually  accompanies  its  severer  forms^ 
and  may  even  be  present  in  its  milder  aspects,  is  sometimes 
seen  among  the  earliest  symptoms.  Again,  we  sometimes 
encounter,  even  quite  early  in  the  disease,  disordered  innerva- 
tion of  the  vital  centers,  showing  a  close  relationship  to  those 
affections  attended  with  profound  blood-poisoning  of  which  the 
local  manifestations,  wherever  situated,  give  but  a  vague  and 
uncertain  indication. 

Dr.  J.  Lewis  Smith  cites  the  case  of  a  girl  of  five  years,  having^ 
malignant  diphtheria,  to  whom  he  was  called  in  consultation, 
and  who  was  carefully  examined  by  the  attending  physician, 
and,  although  he  closely  inspected  the  fauces,  there  was  na 
appearance  which  indicated  the  nature  of  the  malady  till  the 
subsequent  day. 

In  several  similar  cases  which  we  have  observed,  there  has 
been  for  a  day,  or  a  portion  of  a  day,  prior  to  visible  exudation, 
complaint  of  soreness  of  the  throat,  or  difficulty  of  swallowing; 
but  the  pain  and  tenderness  seemed  to  be  in  the  deeper  tissues 
of  the  neck.  The  treatment  of  the  local  inflammation  by  the 
most  reliable  and  efficient  antiseptics  and  disinfectants,  com- 
menced at  the  earliest  possible  moment,  and  repeated  at  short 
intervals,  does  not  prevent  the  occurrence  of  indubitable  symp- 
toms of  blood-poisoning  in  cases  of  severe  type. 

Just  why  the  pseudo-membrane  is  so  prone  to  show  itself 
first  on  the  tonsils,  has  never  been  satisfactorily  explained. 
Extirpation  of  the  tonsils  does  not  prevent  infection.  In  its 
physical  properties,  the  exudation  is  identical  with  the  fibrin 
of  the  blood.  It  has  an  alkaline  reaction,  swells,  and  becomes 
transparent  in  strong  acetic  acid,  and  is  disintegrated  or  dis- 
solved by  caustic  alkalies.  According  to  Weigert,  the  fibrin  is 
derived  mainly  from  inflammatory  exudation,  which  transudes 
from  the  capillary  walls,  and  which  is  coagulated  by  ferment 
derived  from  disintegrated  leucocytes.  The  mucous  membrane 
beneath  the  exudate  is  more  or  less  necrotic,  and  the  sub- 
mucous layer  is  also  necrotic  in  bad  cases.  As  the  inflamma- 
tion subsides,  the  necrosed  portion  of  mucous  membrane 
sloughs  off,  together  with  the  pseudo-membrane,  and  the 
epithelial  surface  is  restored  by  outgrowth  from  neighboring 
cells. 

Several  successive  membranes  may  form  at  the  same  site, 
and  this  is  especially  the  case  when  they  are  forcibly  stripped 
off.  When  left  to  take  its  natural  course,  the  exfoliation  occu- 
pies several  days.  While  the  pseudo-membrane  is  forming,  its 
thin  edges  shade  into  the  surrounding  area  of  inflammation ; 


DIPHTHERIA— PA  THOL  OGT.  355 

but  after  a  time,  if  repair  is  about  to  begin,  the  patches  thicken 
and  wrinkle  about  the  edges,  which  become  raised  above  the 
surrounding  unaffected  mucous  membrane.  Sometimes,  owing 
to  effusion  of  serum  or  ulceration  beneath,  the  pseudo-mem- 
brane sloughs  off  in  one  entire  mass :  but  more  often  it  melts 
down  imperceptibly,  or  comes  away  in  fragments.  Abrasions 
of  the  mucous  membrane  aid  the  spread  of  the  virus,  by  afford- 
ing new  fields  for  infection  ;  hence  the  danger  of  forcibly  strip- 
ping off  the  false  membrane,  and  exposing  raw,  bleeding 
surfaces. 

The  lymphatic  glands  of  the  neck  are  apt  to  be  the  seat  of 
hyperplasia.  This  is  especially  true  if  the  nares  are  involved. 
Sometimes  the  cellular  tissue  surrounding  the  gland  becomes 
infiltrated  and  greatly  swollen.  In  either  event,  as  a  rule,  the 
swelling  subsides  without  suppuration.  In  malignant  cases  the 
odor  from  necrotic  tissues  is  pronounced.  There  may  be  deep 
sloughing  or  even  gangrene  at  the  site  of  local  inflammation, 
and  hemorrhages  are  not  uncommon  from  various  portions  of 
the  affected  mucous  membrane. 

The  spleen,  and  the  liver  also,  may  become  hyperemic.  The 
ventricles  of  the  heart  are  often  dilated ;  but  "  heart  failure," 
is  due  usually  to  poisoning  of  the  pneumogastric  center.  Peri- 
carditis is  occasionally  observed,  and  in  a  few  instances  a 
granular,  or  fatty  degeneration  of  the  heart  walls  has  been 
observed.  As  a  result,  the  heart  walls  become  softer  in  con- 
sistence, and  extravasations  of  blood  take  place  in  them. 

The  kidneys  are  often  the  seat  of  organic  changes  quite  early 
in  the  progress  of  the  disease.  There  is  more  or  less  granu- 
lar deposit  in  the  renal  cells,  and  the  cells  themselves  are  often 
detached  so  as  to  block  up  the  tubes.  They  are  mixed  with 
hyaline  casts. 

Various  pathological  changes  have  been  noticed  in  the  nerv- 
ous system,  particularly  by  Charcot  and  Vulpian,  who  were 
the  first  to  record  their  investigations  in  this  direction.  Oertel 
in  1 87 1  found  many  extravasations  in  the  substance  of  the 
brain,  spinal  cord,  and  spinal  nerves,  in  a  case  where  death  had 
occurred  from  diphtheritic  paralysis  with  general  atrophy  of 
muscle.  Dejerine,  in  five  cases  of  death  in  children  from  diph- 
theritic paralysis,  found  in  each  instance  changes  strictly  limited 
to  the  nerves  supplying  the  paralyzed  parts.  These  changes 
consisted  in  a  degeneration  of  the  anterior  roots  similar  to  that 
which  takes  place  in  the  distal  end  of  a  nerve  after  section. 
He  attributed  the  degeneration  to  changes  in  the  gray  matter 
of  the  anterior  cornua.  Whether  the  nerve  lesion  accompany- 
ing these  paralyses  is  central  or  peripheral,  is  not  definitely  set- 
tled.    Vulpian,  Abercrombie,  Dr.  Percy  Kidd  and  others,  hold 


356  THE  DISEASES  OF  CHILDREN. 

to  the  former  opinion,  while  Drs.  Hughlings, Jackson,  Woakes, 
and  others  equally  eminent  consider  that  the  paralysis  is  due 
to  a  high  degree  of  dilatation  of  the  nerve  vessels,  and  conse- 
quent exudation  in  the  nerve  sheaths,  causing  compression  of 
the  motor  fibers. 

In  a  certain  proportion  of  cases,  the  skin  shows  an  erythe- 
matous eruption  strikingly  resembling  that  of  scarlatina  ;  but  it 
is  not  so  generally  diffused,  and  does  not  extend  over  the  sur- 
face of  the  body  in  the  regular  way  in  which  it  does  in  the 
simple  form  of  this  latter  disease.  It  is  not  common  for  the 
eruption,  however  extensive,  to  be  followed  by  desquamation. 

In  nasal  diphtheria,  it  is  not  uncommon  for  pus  to  form 
underneath  the  pseudo-membrane  formed  within  the  nares  and 
perforate  the  nasal  duct,  or  even  to  burrow  through  the  over- 
lying cuticle. 

Symptoms. — In  diphtheria  the  prodromal  symptoms  are  usu- 
ally slight  and  ill-defined,  and  seldom  continue  longer  than 
twenty-four  or  thirty-six  hours.  They  may  be  wanting  alto- 
gether. When  present  they  consist  of  lassitude,  headache, 
muscular  pains,  fever,  and  pain  on  swallowing.  In  severe 
cases,  there  may  be  chilliness,  even  rigors,  nausea  and  vomit- 
ing, and  in  infants  the  disease  may  be  inaugurated  with  convul- 
sions. Except  in  very  severe  cases,  the  fever  does  not  run 
high.  The  temperature  is  rarely  above  ioi°  or  102°.  Even 
in  mild  cases  there  is  commonly  a  nasal  quality  to  the  voice, 
which  may  become  more  marked  as  the  disease  progresses. 
An  examination  of  the  throat  shows  the  fauces  to  be  red  and 
somewhat  swollen,  but  more  so  on  one  side  than  the  other. 
The  uvula  is  usually  increased  in  size  and  of  a  bright-red  color. 
On  one  and  sometimes  on  both  tonsils,  there  will  be  observed 
a  gray  or  yellowish-white  opaque  patch,  which  seems  to  be  plast- 
ered onto  the  anterior  surface.  This  patch  may  be  round  or  oval 
in  outline,  or  perhaps  more  commonly  in  the  very  beginning, 
appear  in  streaks,  which  afterward  coalesce  into  an  opaque  and 
tough  pseudo-membrane,  which  seems  set  in  the  mucous  mem- 
brane like  a  watch-crystal  in  its  case. 

In  the  first  few  hours  of  the  disease,  the  exudation  may  be 
filmy  and  transparent  in  character,  resembling  that  often  seen 
in  simple  angina  ;  but  very  soon  it  becomes  opaque,  tough  and 
leathery,  and  dips  down  into  the  mucous  membrane  so  that  it 
cannot  be  detached  except  by  the  use  of  considerable  force. 
In  case  force  is  used  and  a  portion  of  the  exudate  is  torn  loose, 
a  raw  and  ulcerated  surface  is  found  beneath,  which  bleeds, 
and  in  a  few  hours  the  pseudo-membrane  is  reformed  over  its 
original  site  and  as  firm  and  adherent  as  before.  The  tenacity 
with  which  this  false  membrane  clings  to  the  deep  tissues  is 


DIPHTHERIA— SYMPTOMS.  357 

one  of  the  pathognomonic  features  of  the  disease.  The  exudate 
which  is  seen  in  simple  or  foHicular  tonsilitis,  can  be  wiped 
off  with  little  effort,  while  that  of  diphtheria  must  be  torn  off, 
if  it  be  artificially  removed. 

As  the  disease  progresses,  the  exudation  spreads  until  it 
covers  or  may  cover  both  tonsils,  the  pharynx,  the  uvula,  the 
pillars  of  the  pharynx,  and  even  portions  of  the  hard  palate. 
Only  in  very  mild  cases  is  the  false  membrane  confined  to  one 
tonsil  or  one  side  of  the  throat.  The  cervical  glands  are  early 
involved  in  most  cases,  and  become  swollen  and  tender.  The 
glandular  swelling  is  bilateral  and  symmetrical.  The  constitu- 
tional symptoms  are  by  this  time  well  marked.  The  pulse  is 
rapid,  120  or  140,  and  weak.  The  first  sound  of  the  heart  is 
perceptibly  weakened.  There  is  a  sense  of  extreme  prostration. 
The  patient  feels  ill  and  looks  pallid.  In  some  cases  there  is 
but  little  if  any  pain  in  deglutition.  The  nerves  of  the  throat 
are  anesthetic.  When  pain  in  swallowing  is  felt,  it  is  usually 
more  on  one  side  than  the  other,  and  generally  on  the  side 
where  there  is  the  least  exudation.  In  mild  cases,  the  exuda- 
tion loses  its  tough,  leathery  character  after  from  two  to  four 
days  and  becomes  darker  in  appearance  ;  it  loosens  about  the 
edges,  which  curl  up  like  parchment.  It  becomes  thinner  and 
softer,  and  either  melts  away  perceptibly,  day  by  day,  or  is 
hawked  up  in  shreds  or  pieces.  If  the  membrane  reaches  to 
any  great  extent  the  vault  of  the  pharynx,  it  invades  the  pos- 
terior nares,  and  comes  forward  to  fill  the  nasal  cavities.  When 
this  occurs,  the  fact  is  evidenced  by  a  thin,  acrid  discharge 
from  the  nose,  of  muco-purulent  character,  which  may  excori- 
ate the  septum,  the  alae  and  upper  lip.  This  discharge  is  very 
offensive  in  odor  and  may  be  mixed  with  blood. 

The  discharge  blocks  up  the  nasal  passages  and  renders 
mouth-breathing  necessary.  Young  infants  cannot  suckle  and 
must  be  fed  with  a  spoon.  Nearly  all  cases  of  nasal  diphtheria 
are  attended  by  swelling  of  the  glands  at  the  angle  of  the  jaw, 
owing  to  their  close  connection  with  the  lymphatic  vessels  of 
the  Schneiderian  membrane.  Indeed,  this  swelling  of  the  par- 
otid and  submaxillary  glands  may  be  the  first  signal  that  the 
disease  has  invaded  the  nasal  passages.  Sometimes  the  connec- 
tive tissue  surrounding  the  glands  becomes  infiltrated,  so  that 
the  entire  neck  is  greatly  swollen.  Epistaxis  is  common  and 
may  be  uncontrollable,  owing  to  the  non-coagulability  of  the 
blood. 

In  cases  which  terminate  favorably,  the  false  membrane  sep- 
arates and  is  not  renewed.  The  swelling  subsides,  the  appetite 
returns,  the  pulse  becomes  stronger,  and  unless  some  complica- 
tion ensues,  a  slow  convalescence  begins.     Often,  however,  the 


358  THE  DISEASES  OF  CHILDREN. 

patient  succumbs  at  the  end  of  a  week,  either  from  exhaustion, 
or  extension  of  the  false  membrane  into  the  larynx,  or  from 
some  other  complication  to  be  presently  described.  The  mind 
is  usually  clear  to  the  very  end,  although,  in  rare  cases,  death 
may  be  preceded  by  delirium  or  coma.  Apathy  is  one  of  the 
singular  characteristic  features  of  diphtheria.  The  patient  does 
not  complain  of  pain,  usually — only  of  being  tired.  Relapses  are 
frequent,  either  from  reinfection  of  the  system,  or  from  other 
causes,  and  in  such  cases  chilliness  is  complained  of ;  the 
temperature,  which  has  been  normal,  or  but  little  above  normal, 
suddenly  rises  to  103°  or  104°,  sinking  again  in  irregular  varia- 
tions ;  the  pulse  is  rapid,  small  and  feeble ;  the  eyes  are 
sunken  and  dull ;  the  strength  rapidly  diminishes ;  the  prostra- 
tion is  extreme;  delirium  comes  on,  and  the  child  quickly  dies. 
The  amount  of  fever  in  diphtheria  varies  greatly.  Even  in 
bad  cases  it  need  not  be  high.  Whether  high  or  low,  it  affords 
no  criterion  by  which  to  estimate  the  gravity  of  the  attack,  un- 
less it  be  abnormally  so.  Albuminuria  occurs  in  about  two- 
thirds  of  the  cases,  but  this  does  not  necessarily  imply  gravity 
in  the  prognosis.  Its  amount  is  greater  usually  in  proportion 
to  the  amount  of  the  exudate.  The  early  appearance  of  albu- 
min in  the  urine — that  is,  within  the  first  forty-eight  hours — 
only  occurs  in  severe  cases.  In  cases  of  mild  or  moderate 
severity,  it  does  not  appear  before  the  third  or  fourth  day.  It 
may  be  delayed  as  late  as  the  ninth  or  tenth  day.  The  urine  is  of 
high  specific  gravity,  and  contains  an  excess  of  urea,  with  hyaline 
and  granular  casts.  The  kidneys  are  in  a  state  of  mild  paren- 
chymatous nephritis ;  but  this  passes  off  as  convalescence  be- 
comes established,  and  rarely  leaves  ill  consequences  behind. 
It  is  rare  for  uremic  symptoms  or  dropsy  to  occur. 

Laryngeal  Diphtheria. — The  diphtheritic  poison,  instead  of 
finding  for  itself  a  nidus  in  the  pharynx,  may  in  exceptional 
cases  develop  in  the  larynx,  the  trachea,  or,  as  in  a  case  we  saw 
some  years  ago,  in  the  upper  bronchi. 

When  diphtheria  invades  the  larynx  primarily,  there  are 
no  special  symptoms  by  which  we  can  differentiate  it  from  true 
membranous  croup,  except  in  those  rare  cases  in  which,  by  an 
extension  upwards,  it  involves  the  pharynx  subsequently,  and 
there  manifests  its  distinctive  peculiarities.  There  is  no  odor 
to  the  breath ;  the  dyspnea  is  not  different  or  greater  ;  and 
indeed  it  is  practically  impossible  to  distinguish  one  from  the 
other,  except  in  cases  where  there  is  a  distinct  history  of 
diphtheritic  exposure.  It  is  this  fact  that  has  led  so  many 
high  authorities  to  regard  the  two  diseases  as  identical. 

In  the  majority  of  cases  of  laryngeal  diphtheria,  however, 
the  larynx  is  not  involved  primarily.     It  is  due  to  an  extension 


DIPHTHERIA— LARYNGEAL.  359 

of  the  inflammation  downward  from  the  pharynx.  This  ex- 
tension to  the  air-passages  often  takes  place  suddenly  and  unex- 
pectedly. The  preceding  symptoms  may  have  been  slight  and 
attracted  but  little  attention.  There  may  have  been  but  a 
modicum  of  inflammation  or  exudation  in  the  pharynx.  The 
whole  array  of  symptoms  may  have  been  of  the  mildest  type, 
when  suddenly  the  breathing  becomes  stridulous,  or  a  croupy 
cough  sounds  the  first  signal  of  danger. 

The  symptoms  which  characterize  membranous  croup  then 
develop  themselves  with  startling  rapidity.  Hoarseness  follows, 
which  may  be  quickly  succeeded  by  aphonia.  The  breathing 
becomes  quick  and  shallow,  or  noisy  and  stertorous.  The  counte- 
nance becomes  cyanotic  and  anxious ;  the  patient  sits  up  or 
tosses  in  bed,  gasping  for  breath,  the  alae  nasi  working  vigor- 
ously with  all  the  accessory  respiratory  muscles  called  into 
action.  The  breathing  is  superficial,  rapid  and  irregular.  Each 
inspiration  is  prolonged  and  high-pitched  ;  the  expirations 
shorter  and  harsh.  The  cough  is  hoarse  or  whispering.  Owing 
to  obstruction  to  the  entrance  of  air,  the  supra-claricular  spaces 
and  the  lower  intercostal  spaces  are  sunken  by  atmospheric 
pressure  during  inspiration. 

The  patient  may  cough  up  pieces  of  membrane  and  thus 
secure  a  temporary  respite  from  impending  death  ;  but  the 
•dyspnea  soon  returns  from  the  re-formation  of  new  membrane. 
Even  where  the  membrane  is  not  coughed  up,  the  dyspnea  is 
paroxysmal.  It  lasts  from  a  few  minutes  to  a  quarter  of  an 
hour,  or  longer.  During  the  periods  of  respite  the  child's  ter- 
ror disappears  ;  his  respiration  becomes  less  noisy  and  stridu- 
lous ;  his  respiratory  movements  are  less  laborious,  and  for  a 
time  he  is  in  a  state  of  comparative  ease.  Still  the  breathing 
does  not  altogether  resume  its  natural  character.  It  is  rapid 
and  audible.  The  alae  nasi  continue  to  work  violently  and 
some  lividity  still  lingers  in  the  countenance.  It  is  rare  that 
enough  membrane  is  coughed  up  to  afford  more  than  partial 
relief.  The  dyspnea  recurs  at  short  intervals,  and  at  each  re- 
currence is  more  severe  than  before,  so  that  the  child  is  speed- 
ily exhausted  in  strength  or  passes  into  a  state  of  semi-asphyx- 
iation. The  forehead  becomes  clammy  and  the  extremities 
cold.  The  lips  become  purple  and  the  face  livid.  Usually,  if 
not  relieved  by  tracheotomy  or  intubation,  the  child  does  not 
survive  more  than  twenty-four  or  thirty-six  hours  from  the 
time  when  the  larynx  was  first  involved.  Sometimes,  however, 
if  the  false  membrane  is  of  limited  extent,  or  is  confined  to  the 
lower  portion  of  the  larynx,  recovery  may  take  place.  In 
other  cases  when  the  child's  strength  is  good  and  time  is 
given  for  the  action  of  suitable  remedies,  a  favorable  change 


360  THE  DISEASES  OF  CHILDREN. 

may  take  place  and  the  stenosis  be  relieved  by  coughing  up  a 
considerable  portion  of  membrane,  which  is  not  thereafter  re- 
newed. An  extension  of  diphtheria  into  the  nares  is  always 
attended  with  danger,  and  into  the  larynx  with  almost  neces- 
sarily fatal  results,  unless  surgical  measures  are  promptly 
resorted  to,  in  which  case  life  may  be  at  least  prolonged, 
and  in  some  cases  undoubtedly  saved.  Laryngeal  diphtheria, 
however,  must  be  regarded  as  the  most  fatal  of  all  infantile 
maladies. 

Complications  and  Sequela. — Diphtheria  is  more  apt  to  com- 
plicate other  diseases,  such  as  measles  and  scarlatina,  than  to 
itself  be  complicated  by  them.  The  extension  of  the  false 
membrane  into  the  larynx  or  the  trachea,  in  the  course  of  an 
attack  of  diphtheria,  is  the  most  serious  of  these  complications. 
The  presence  of  albumin  in  the  urine  is  by  all  means  the  most 
common,  occurring  in  probably  two-thirds  of  the  cases,  regard- 
less of  gravity.  But  its  presence  or  absence  is  not  to  be  seri- 
ously regarded.  In  rare  cases  there  is  local  edema,  and  possibly 
anasarca ;  but  the  nephritis  which  is  set  up  by  the  diphtheria 
is  usually  of  temporary  duration  and  trifling  in  results. 

Among  the  sequelae,  paralysis  of  local  muscles  is  exceedingly 
common,  and  is  liable  to  follow  in  the  wake  of  the  disease,  how- 
ever mild  the  attack  may  have  been.  This  paralysis  may  be 
partial,  amounting  to  slight  impairment  of  function,  or  it  may 
be  complete.  It  may  be,  and  commonly  is,  limited  to  a  single 
group  of  muscles,  or  it  may  involve  in  succession  almost  the 
whole  voluntary  muscular  system.  The  advent  of  these  paraly- 
ses is  always  insidious,  and,  as  a  rule,  is  noticeable  during  the 
second  or  third  week  of  convalescence.  Trousseau  mentions  a 
case  in  which  the  paralysis  manifested  itself  some  days  before 
the  complete  disappearance  of  the  false  membrane.  McKen- 
zie  states  that  the  paralysis  may  develop  as  late  as  the  sixth 
week  of  convalescence.  In  all  cases  their  advance  is  gradual, 
and  they  may  continue  to  extend  for  several  weeks  after  their 
first  appearance.  The  muscles  most  frequently  affected  are 
those  of  the  soft  palate,  the  eyes,  and  those  of  the  extremities. 
When  the  former  are  affected,  a  nasal  tone  is  given  to  the  voice, 
and  there  is  difficulty  in  phonation,  owing  to  the  impossibility 
of  closing  the  naso-pharyngeal  passage.  A  patient  thus  will 
pronounce  rub,  raw,  head, //^«/,  and  egg,  enk.  In  connection 
with  indistinct  articulation,  there  is  frequently  strabismus,  di- 
latation of  pupils,  and  imperfect  vision.  The  taste  is  often  more  or 
less  blunted,  and  sometimes  the  power  of  expectoration  is  lost. 
In  some  cases  there  is  impairment  of  the  pneumogastric,  and  a 
nervous  cough  is  developed,  or  the  respiration  becomes  sighing, 
as  if  from  exhaustion.     A  year  ago  we  took  care  of  a  pair  of 


DTPHTHERI A— TREATMENT.  361 

twins,  five  years  old,  simultaneously  sick  with  mild  diphtheria. 
During  convalescene  the  little  boy  began  twitching  his  eyelids, 
and  this  involuntary  muscular  action  subsequently  extended  to 
nearly  all  parts  of  the  body.  After  a  month  or  six  weeks  he 
made  a  good  recovery,  and  has  not  been  troubled  since. 
Some  six  months  after  recovery  from  the  diphtheria,  his  twin 
sister  began  sighing  at  frequent  but  irregular  intervals,  and  this 
increased  to  such  an  extent  that  she  was  brought  back  to  me 
for  treatment,  and  she  also  made  a  good  recovery  in  the  course 
of  a  few  weeks. 

Paralysis  of  the  extremities  is  occasionally  met  with,  but  is 
seldom  complete,  being  generally  of  an  ataxic  character,  ren- 
dering the  movements  uncertain,  tottering  or  hesitating.  In 
such  cases  there  is  numbness  and  tingling  in  the  afTected  mem- 
bers. Cardiac  syncope  is  not  uncommon,  even  in  cases  that 
show  no  other  sign  or  evidence  of  neurotic  complication.  It  is 
not  without  danger,  as  numerous  cases  are  recorded  of  sudden 
death  after  convalescence  was  supposed  to  be  well  established. 
Violent  exercise  should  be  strictly  prohibited  to  those  who  are 
recovering  from  diphtheria,  until  a  full  restoration  of  strength 
has  been  secured. 

There  is  some  tendency  of  the  diphtheritic  membrane  to 
extend  down  the  esophagus,  and  invade  the  stomach.  It  is  in 
such  cases  that  we  have  such  repugnance  to  and  intolerance  of 
food.  Vomiting  is  frequent,  although  not  always  present. 
Epigastric  and  precordial  pain  is  usually  complained  of,  and  is 
sometimes  a  marked  and  distressing  symptom. 

Treatment. — The  successful  treatment  of  diphtheria  must 
be  based  upon  the  law  of  similia.  Any  other  treatment  must 
be  empirical,  uncertain  and  unsafe.  As  we  have  seen  in  the 
preceding  pages,  the  disease  in  its  malignant  form  is  character- 
ized by  profound  depression  of  the  vital  forces,  and  a  demoral- 
ization of  the  blood  arises  in  consequence. 

This  is  sometimes  manifested  prior  to  the  visible  formation 
of  any  distinctive  false  membrane,  either  in  the  throat  or  else- 
where. In  such  cases  any  attempt  to  abort  or  control  the  dis- 
ease by  local  applications  would  be  manifestly  absurd.  Even 
where,  as  is  the  case  usually,  the  formation  of  false  membrane 
precedes  the  constitutional  symptoms,  the  employment  of 
escharotics  and  germicides,  with  the  hope  of  destroying  the 
poison  at  the  seat  of  infection,  has  proven  a  dismal  failure  in 
the  vast  majority  of  cases.  In  saying  this  we  do  not  mean  to 
decry  the  use  of  local  measures  altogether,  for  we  firmly  be- 
lieve in  them — some  of  them — as  will  be  seen  presently.  What 
we  do  mean  is,  that  the  use  of  strong  carbolic  acid,  nitrate  of 
silver,  or  the  bichloride  of  mercury,  as  a  destroyer  of  germs^ 


362  THE  DISEASES  OF  CHILDREN. 

and  therefore  a  remedy  for  this  disease,  is  not  sanctioned  by 
common  sense,  by  scientific  study,  nor  by  clinical  experience. 

In  the  milder  forms  of  the  disease,  we  are  confident  that 
such  measures  as  we  have  just  mentioned  are  not  only  useless 
but  most  pernicious.  There  are  antiseptics  of  the  first  class, 
which  are  entirely  free  from  objection,  that  could  not  do  harm 
if  applied  properly  to  a  throat  in  perfect  health,  and  which 
nevertheless  are  of  accredited  germicidal  power,  and  of  proven 
efficacy.  One  of  the  best  of  these  and  one  that  has  stood  the 
longest  clinical  test  is  permanganate  of  potash.  It  has  no 
equal  as  a  deodorizer.  It  can  be  used  as  a  gargle,  if  the  patient 
is  old  enough,  or  it  may  be  used  as  a  spray  by  any  form  of 
atomizer.  One  of  the  best  methods  of  using  this  or  any  of 
the  other  antiseptics  is  by  means  of  an  Alpha  syringe  with  an 
acorn  tip.  This  throws  a  continuous  stream,  and  it  can  be  used 
as  a  nasal  douche,  or  it  can  be  made  to  reach  the  post-nasal 
and  pharyngeal  surfaces  at  will.  While  the  permanganate  is 
quite  harmless  if  taken  in  tangible  doses,  its  effects  are  secured 
by  using  it  in  the  strength  of  one  or  two  grains  to  the  ounce 
of  water. 

Eucalyptol  is  a  remedy  highly  spoken  of  by  Dr.  E.  M.  Hale. 
The  liquor  calcis  chlor.  has  many  advocates,  and  is  highly 
praised  by  Neidhard  ;  but  its  efficiency  seems  to  be  limited  to 
mild  cases,  in  which  there  is  but  little  false  membrane. 

But  the  local  remedy  par  excellence,  is  peroxide  of  hydrogen. 
It  has  many  advantages  over  any  other,  and  can  be  used  by 
spray,  lavage,  gargling  or  douching.  It  can  be  swallowed,  even 
by  infants,  semi-diluted,  with  impunity.  In  taste  it  is  scarcely 
less  disagreeable  than  water.  It  has  no  toxic  dose.  Pus  can- 
not exist  in  its  presence.  It  is  deoderant  and  germicidal.  It 
loosens  the  false  membrane  from  its  attachments  by  destroy- 
ing the  purulent  matter  underneath  and  around  it,  and  thus 
hastens  its  elimination.  It  does  more  than  this.  When  brought 
into  contact  with  the  mucous  surfaces,  it  is  absorbed  to  a  greater 
or  less  extent,  and  thus  assists  in  the  essential  process  of  blood 
oxydation  and  purification.  In  other  words,  its  antiseptic 
properties  extend  beyond  local  contact,  and  it  helps,  besides, 
the  oxygenation  of  the  blood,  thus  acting  as  a  powerful  volatile 
stimulant. 

In  order  to  secure  the  best  results  from  the  use  of  the  per- 
oxide, certain  precautions  must  be  taken.  So  far  as  our  pres- 
ent knowledge  goes,  that  prepared  by  Charles  Marchand  is  the 
best.  Even  this  preparation  is  very  unstable  and  rapidly  de- 
teriorates unless  kept  well  corked,  and  in  a  cool  place.  For 
this  reason,  although  needed  in  large  quantities,  it  should  be 
obtained  in  the  smallest  packages  (4  oz.),  and  these  should 


DIPHTHERIA— TREATMENT.  363 

only  be  opened  as  required  for  immediate  use.  The  15  vol- 
ume strength  is  to  be  preferred.  In  the  early  stages  of  the 
disease,  this  strength  can  be  used  by  spray  without  dilution. 
The  oxygen  contained  in  this  preparation  has  a  strong  affinity 
for  all  metals  except  gold,  silver  and  platinum,  and  hence,  the 
atomizer  used  should  consist  only  of  glass  and  rubber.  When 
the  peroxide  is  first  used  in  full  strength,  it  produces  a  slight 
smarting  sensation  ;  but  this  is  trifling  and  no  irritation  results. 
When  thrown  up  the  nose  it  should  be  diluted  one-half 
with  water.  If  by  reason  of  a  too  copious  or  too  violent  irriga- 
tion, the  patient  should  swallow  any  considerate  portion  of  the 
liquid,  no  apprehension  need  be  felt,  for  we  often  give  it  in  this 
way  for  its  antiseptic  influence  over  the  false  membrane  which 
has  been  disintegrated  and  taken  into  the  stomach.  It  should 
be  used  as  often  as  the  strength  of  the  patient  will  permit.  In 
the  early  stages  this  means  at  least  once  an  hour. 

There  are  many  other  local  applications  which  have  their 
advocates,  but  they  are  not  to  be  compared  with  those  which 
have  just  been  named.  Boracic  acid,  chlorate  of  potash,  bro- 
mine, iodine,  bichloride  of  mercury,  and  a  long  list  of  other 
remedies  have  been  tried  and  found  wanting.  They  all  have 
objectionable  features  which  render  them  either  unreliable  or 
unsafe  for  general  use.  Every  now  and  again  the  newspapers 
teem  with  some  old  woman's  remedy  which  has  been,  or  seems 
to  have  been,  useful  in  cases  of  diphtheria.  The  laity  are  much 
given  to  credit  any  story  of  a  case  cured,  even  by  such  apocry- 
phal means,  and  as  these  measures  are  generally  harmless,  if 
impotent,  the  best  way  seems  to  be  to  permit  their  use,  under 
protest  or  without,  while  other  and  better  accredited  remedies 
are  being  actively  employed. 

In  case  the  domestic  or  empirical  remedy  is  of  questionable 
innocency,  the  onus  of  responsibility  for  its  use  should  be 
thrown  upon  the  user.  Thus,  if  one  is  asked  if  a  certain  rem- 
edy or  measure  of  unknown  value  suggested  by  the  patient's 
friends  or  nurse  may  be  used,  the  best  disposition  to  be  made 
of  the  matter  is  to  say,  "  Why  yes,  certainly,  use  it  if  you 
choose  ;  but  you  must  take  the  responsibility  of  doing  so.  Thus 
we  hear  all  the  time  about  the  local  application  of  sulphur,  of 
lemon  juice,  of  pineapple  juice,  etc.,  and  of  the  most  incred- 
ible cures  effected  by  their  miraculous  powers ;  and  while  the 
experienced  physician  may  know  of. their  utter  incompetency, 
it  is  cruel  to  deprive  an  anxious  and  despairing  parent  of  even 
a  ray  of  hope  thus  furnished,  even  though  he  may  know  that 
even  this  ray  is  purely  fanciful. 

Internal  Treatment. — The  drug  which  comes  the  nearest  to 
being  a  true  similimum  of  diphtheria  in  its  gravest  aspects  is 


364  THE  DISEASES  OF  CHILDREN. 

mercurius,  and  the  physician  who  achieved  the  greatest  success 
in  the  treatment  of  it  in  the  colonial  outbreak  which  marked 
its  advent  into  this  country,  referred  to  in  the  beginning  of 
this  chapter,  was  Dr.  Douglas,  of  Boston,  who  succeeded  in 
saving  many  cases  by  the  heroic  use  of  calomel.  It  was  the 
first  time  in  America  that  mercury  was  used  in  acute  inflam- 
matory affections.  At  the  present  day  it  is  used  by  both 
schools  of  medicine  successfully,  but  of  course  in  very  differ- 
ent preparations  and  doses.  Old-school  physicians  report  a 
great  many  cases  treated  successfully  with  the  bichloride  in 
doses  of  one-tenth  to  one-sixtieth  of  a  grain,  repeated  every 
few  hours  until  the  membrane  is  detached.  Others  of  this 
school  still  prefer  the  time-honored  "  mild  chloride  "  (calomel) 
in  doses  of  one  to  five  grains  every  one  or  two  hours  till  its 
characteristic  purgation  is  produced.  Our  own  school,  using 
the  same  drug  in  the  third,  the  thirtieth  or  the  one-hundredth 
attenuation,  seems  to  have  precisely  the  same  success,  which 
demonstrates,  as  clearly  as  a  single  illustration  can  prove  a 
thing,  that  it  is  not  the  quantity,  but  the  specific  power  of  the 
medicine,  which  renders  it  curative.  The  particular  prepara- 
tion of  mercury  (mercurius)  which  is  best  adapted  to  these 
cases  is  not  well  settled.  Some  physicians  prefer  the  cyanuret 
of  mercury ;  others  the  iodides,  especially  in  strumous  subjects. 
All  of  the  mercurial  preparations  present  a  fairly  good  picture 
of  diphtheria.  Our  own  preference  is  for  mere.  cor.  in  cases 
where  there  is  a  large  amount  of  exudate,  great  fetor  and  also 
great  prostration.  We  prefer  the  iodide  of  mercury  when  the 
glands  are  much  involved  and  the  neck  is  greatly  swollen.  It 
is  especially  useful  in  scrofulous  subjects  as  already  stated, 
and  is  well  adapted  to  those  cases  which  early  show  a  tendency 
to  malignancy.  The  countenance  is  livid  and  the  discharges 
from  both  throat  and  nose  are  putrid ;  the  saliva  is  profuse 
and  stringy.  There  is  also  great  pain  in  swallowing.  Kali 
bichrovticum  undoubtedly  ranks  next  to  mercurius  as  truly 
homeopathic  to  diphtheria.  In  mild  cases  or  those  of  moder- 
ate intensity,  it  often  takes  first  rank.  It  is  especially  indicated 
in  those  cases  which  show  a  tendency  to  laryngeal  complica- 
tion. Dr.  Richard  Hughes,  of  London,  says  of  kali  bich.,  "  In 
nasal  diphtheria  I  find  it  specific  ;  in  laryngeal,  it  does  all  that 
medicine  can  do."  Dr.  Mitchell  says  the  special  indications 
are  :  "  Mucous  membrane  deeply  affected  and  ulcerated  ;  pain 
in  the  throat  ;  painful,  difficult  swallowing ;  stringy,  tough 
mucus ;  the  exudation  is  of  a  yellowish  or  yellowish-white 
color,  and  is  of  a  firm,  fibrous  nature,  thrown  out  in  large 
quantities,  covering  both  tonsils  and  tending  to  extend  into 
the  nares  and  larynx.     The  characteristic  difference,"  he  adds. 


DIPHTHERIA— REMEDIES.  365 

"between  kali  bich.  and  mere,  iod.,  is  the  more  fibrinous  con- 
sistency of  the  exudate  under  kali,  while  mercury  has  a  softer 
and  more  pasty  pseudo-membrane."  Kali  should  be  given  in 
solution.  Two  to  three  grains  of  the  3X  should  be  dissolved 
in  half  a  glass  of  water,  and  a  teaspoonful  of  this  given  everj' 
hour,  or  every  half-hour  if  the  case  is  urgent. 

In  malignant  cases,  where  there  is  considerable  exudate  of  a 
dirty  brown  color,  of  tough  consistence,  and  great  fetor  of 
breath,  we  give  the  kali  in  trituration,  depositing  it  directly  on 
the  affected  surfaces  by  means  of  a  powder-blower,  repeating 
the  operation  at  intervals  of  one  or  two  hours  until  there  is  a 
manifest  amelioration  of  symptoms. 

The  attempt  has  been  made  to  dispose  of  the  pseudo-mem- 
brane, and  thus  get  rid  of  at  least  the  outward  and  visible 
signs  of  the  disease  by  means  of  certain  digests,  such  as  pep- 
sin and  papoid,  but  without  success.  All  such  efforts  are  based 
upon  a  very  superficial  and  erroneous  idea  of  the  true  nature 
and  real  danger  of  the  affection.  It  cannot  be  too  frequently 
or  too  emphatically  stated  that  diphtheria  is  a  systemic  or  gen- 
eral disease  ;  in  all  cases,  to  a  greater  or  less  extent,  infecting 
the  entire  organism,  the  pseudo-membrane  being  in  some  cases 
more  prominent  than  in  others,  but  never  in  any  case  consti- 
tuting the  entire  malady.  It  would  certainly  show  poor  gen- 
eralship— to  use  an  army  simile — to  concentrate  all  or  most  of 
one's  forces  on  a  single  outpost,  while  the  main  body  of  the 
enemy  was  known  to  be  in  ambush  in  the  immediate  vicinity. 

Arsenicum. — This  remedy  is  not  used  in  diphtheria  as  often 
as  it  should  be.  It  is  very  useful  in  some  malignant  forms,  ac- 
companied by  great  debility,  pallid  countenance,  puf^ness  of 
face  and  eyes,  urine  scanty,  feeble  pulse,  acrid  discharge  from 
nose,  very  fetid  breath  and  painful  deglutition. 

Apis  mel. — Uvula  elongated  and  edematous ;  pufifiness  of 
mucous  membrane  extending  onto  hard  palate  ;  urine  scanty  or 
suppressed  ;  burning  and  stinging  dryness  of  throat ;  swelling 
of  the  cervical  and  submaxillary  glands ;  where  there  is  edema 
of  the  glottis ;  fiery  redness  or  pufifiness  of  a  purplish  tint ; 
very  useful  in  cases  of  laryngeal  diphtheria,  when  other  symp- 
toms as  above  correspond. 

Arum  triphyllum. — The  indications  for  this  remedy  are  fetid 
breath  and  great  acridity  of  discharges  from  mouth  and  nose ; 
discharges  excoriate  and  form  large  crusts  about  the  orifices ; 
diphtheritic  deposit  excessive  and  mixed  with  more  or  less 
ulceration.  The  acrid  character  of  the  discharges  creeping  be- 
yond the  mucous  membrane  and  affecting  the  adjacent  skin,  is 
the  key-note  for  this  drug. 

Lachesis. — Malignant  cases:  exudation  worse  on  left  side; 


366  THE  DISEASES  OF  CHILDREN. 

mucous  membrane  livid  ;  great  difficulty  and  pain  on  swallow- 
ing; great  weakness;  delirium  well  marked;  bad-smelling 
stools ;  ulceration  of  mucous  membrane.  The  marked  charac- 
teristics of  lachesis  are  lividity  of  mucous  membrane ;  inflam- 
mation worse  on  left  side,  and  painful  deglutition. 

Ferrum  per  chloride. — The  tincture  of  the  perchloride  of  iron, 
as  well  as  the  muriatic  tr.,  are  used  extensively  by  the  old 
school  of  practice,  and  apparently  with  good  results.  They 
use  these  iron  preparations  both  locally  and  internally.  There 
is  no  doubt  that  iron,  if  presented  in  an  assimilable  form,  may 
counteract,  to  some  extent,  at  least,  the  anemia  which  attends 
all  cases  of  diphtheria ;  but  even  as  a  tonic  our  ferrum  met. 
and  ferrum  phos.  are  superior  to  the  crude  tinctures. 

Dr.  Hale  suggests  that  as  muriatic  acid  is  of  known  value  in 
these  cases,  that  it  is  the  combined  acids  in  these  iron  prepa- 
rations that  render  them  useful,  rather  than  the  metal  itself. 
The  indications  for  them  are  not  clear  ;  at  least  they  are  not 
clearly  defined  as  compared  with  other  remedies  already  spoken 
of,  or  to  be  mentioned  hereafter.  They  may  perhaps  be  used 
with  advantage  intercurrently  with  other  medicines  more  spe- 
cifically indicated. 

Phytolacca. — Is  very  useful  in  cases  of  mild  or  moderate  inten- 
sity, attended  with  pain  on  movements  of  tongue  and  neck;  adapt- 
ed to  cases  that  in  the  beginning  simulate  follicular  tonsilitis,  but 
with  fetor  of  breath  and  weakness  unusual  to  this  latter  dis- 
ease ;  in  addition  to  prostration  there  is  drowsiness ;  constant 
inclination  to  swallow  ;  nausea,  vomiting  and  diarrhea.  This 
remedy  is  of  no  value  in  malignant  cases. 

M.  Teste,  of  Paris,  is  a  strong  advocate  of  the  use  of  bromine 
in  diphtheria.  His  high  standing  and  large  experience  in  this 
disease  entitle  his  opinion  to  more  than  ordinary  weight.  He 
gives  the  bromine  in  solution,  the  strength  of  which  is  one  grain 
to  one  hundred  drops  of  water.  Of  this  he  gives  two  to  three 
drops  in  a  little  sweetened  water  every  quarter  of  an  hour,  or 
less  often  in  mild  cases.  He  also  advocates  the  free  evaporiza- 
tion  of  the  medicine  in  the  sick  room,  both  as  a  further  means 
of  cure  and  as  a  prophylactic  for  nurses  and  attendants. 

Treatment  of  Complications  and  SequelcB. — It  has  already  been 
stated  that  next  to  diphtheritic  croup,  the  complication  most  to 
be  dreaded  is  heart  syncope.  It  cannot  be  too  strongly  impressed 
upon  the  mind  of  the  reader  that  the  real  danger  in  diphtheria 
— the  one  factor  in  the  disease  that  is  of  graver  import  than 
any  other — is  exhaustion  of  strength  (vitality).  This  is  a  danger 
that  menaces  all  cases,  mild  as  well  as  malignant.  This  danger 
increases,  of  course,  as  the  severity  of  the  attack  increases,  and 
it  remains  a  menace  even  after  all  visible  manifestations  of  the 


DIPHTHERIA— TREATMENT  OF  SE^UEL^E.        367 

disease  have  vanished.  The  peril  from  suffocation,  even  in 
laryngeal  cases,  is  small  compared  with  this  danger  from  ex- 
haustion of  the  vital  energies. 

In  the  most  malignant  case,  nature  will  ultimately  overcome 
her  enemy,  if  the  strength  can  be  kept  up,  and  the  deposit  can 
be  arrested.  In  trying  to  meet  the  requirements  of  imperiled 
cases  from  this  cause,  we  are  handicapped  by  repugnance  to 
food,  and  the  apathy  which  fails  to  appreciate  the  necessity  of 
eating.  The  difficulty  of  swallowing  renders  it  necessary  to 
employ  foods  and  stimulants  in  the  most  concentrated  form. 
We  make  bold  to  say  that  for  the  purpose  here  indicated  alco- 
hol is  our  "  sheet-anchor."  It  should  not  be  given  in  the  form 
of  milk  punch  or  egg  nog.  Wines  are  of  uncertain  value  ;  good 
brandy  is  difficult  to  obtain.  Old  rye  whisky  will  answer  a  good 
purpose;  but  in  lieu  of  this,  pure  (95  per  cent.)  alcohol  will  be  found 
most  available.  This  should  be  given  in  small  and  repeated  doses, 
sufficiently  diluted  to  be  easily  swallowed.  A  little  sugar  may 
be  added  to  render  it  more  smooth  and  palatable.  In  very  bad 
cases,  this  should  be  given  to  the  verge  of  intoxication.  It  is 
not  only  a  quick  stimulant,  it  is  more — it  is  one  of  the  best 
antiseptics  known.  It  is  interesting  to  note  with  what  facility 
it  dissolves  the  diphtheritic  exudation  in  the  throat,  lowers  the 
temperature,  and  calms  the  pulse.  In  young  children  and  in- 
fants it  should  be  used  tentatively  and  with  due  caution  ;  but 
it  is  our  firm  belief  that  alcohol,  when  properly  used,  has  saved 
more  lives  than  any  other  one  remedy.  When  whisky  is  used 
it  should  be  given  in  the  form  of  *'  sling "  or  "  toddy,"  i.  e.y 
mixed  with  hot  water  and  sugar.  If  alcohol  is  used  in  any 
form,  it  should  be  given  regularly  and  systematically.  It  is  the 
"  little  and  often,"  rather  than  the  toxic  dose,  that  is  desired. 
During  convalescence  the  heart  should  be  examined  at  every 
visit,  and  if  its  action  is  enfeebled  or  any  irregularity  is  notice- 
able, cactus  (or  caciina,  its  active  principle),  with  nux  vomica, 
should  be  given.  "  Digitalis  and  strophanthus  are  close  ana- 
logues of  cactus,  and  can  be  given  in  similar  doses ;  but  they 
are  not  as  well  borne  by  the  stomach,  being  bitter  and  nauseous, 
while  cactus  is  quite  tasteless." — Hale. 

Cactina  can  be  used  in  tincture,  or  trituration,  or  can  be  in- 
jected hypodermically.  A  grain  of  the  first  centesimal  tritura- 
tion is  equal  to  one  drop  of  a  good  tincture. 

If  sudden  collapse  is  threatened,  a  hundredth  of  a  grain  or 
drop  of  glonoin  may  be  given  first,  for  its  immediate  effect, 
and  the  cactus  may  be  given  afterwards.  If  the  respiratory  func- 
tion is  threatened  with  collapse,  a  drop  or  two  of  ainyl  nitrite 
may  be  given  by  inhalation,  and  followed  by  cactus  or  digitalis 
or  veratrum  album. 


368  THE  DISEASES  OF  CHILDREN. 

In  paralyses  that  do  not  immediately  threaten  the  heart,  such 
as  chorea,  sighing  respiration,  local  paralysis  of  certain  muscles 
or  groups  of  muscles,  gelsemium  is  almost  a  specific.  If  the 
limbs  are  paralyzed,  strychnia  phosphate  2x,  a  grain  three  or 
four  times  daily,  may  be  given  until  they  regain  their  power. 
In  some  cases  that  are  slow  to  recover,  we  have  seen  imme- 
diate and  steady  improvement  manifested  under  the  use  of  the 
faradic  current.  It  should  be  used  daily  as  strong  as  can  be 
borne  without  discomfort. 

Intubation  and  Tracheotomy. — It  must  be  conceded  that 
the  internal  treatment  of  laryngeal  diphtheria  has  not  been 
attended  with  that  success  which  inspires  either  hope  or  confi- 
dence. Cases  undoubtedly  do  recover — enough  to  encourage 
effort  and  prevent  despair ;  but,  except  in  primary  cases  and  in 
robust  constitutions,  when  the  false  membrane  extends  from  the 
pharynx  below  the  epiglottis  and  invades  the  larynx,  the  recov- 
eries are  few  and  far  between.  The  danger  of  suffocation  stares 
us  in  the  face,  and  remedies  calculated  to  remove  the  stenosis 
are  too  slow  of  action  to  meet  the  emergency. 

Tracheotomy,  which  has  undoubtedly  saved  many  cases  of 
membranous  croup,  is  practically  inadmissible  here,  for  the  tem- 
porary and  transient  relief  of  the  stenosis  is  almost  certain  to  open 
the  door  to  a«/c-infection  through  the  surgical  wound.  Besides 
this  the  shock  of  the  operation  is  to  be  considered.  Statistics 
of  tracheotomy  in  laryngeal  diphtheria  do  not  or  have  not 
shown  a  sufficient  number  of  proportionate  recoveries  to  give  it 
standing  even  as  a  dernier  ressort. 

O'Dwyer's  method  of  relieving  the  stenosis  by  means  of  in- 
tubation has  much  to  recommend  it.  At  the  same  time,  its 
best  results  are  secured  only  by  an  expert  operator.  It  is  not 
an  easy  matter  to  discover  the  location  of  the  laryngeal  orifice, 
and  to  insert  the  tubes  while  an  inexperienced  nurse  or  a  nerv- 
ous mother  is  handling  a  refractory  and  half  suffocated  child. 

The  best  results  from  intubation  are  therefore  found  in  hos- 
pital practice  ;  but  there  is  no  reason  why  any  physician  should 
not  make  himself  familiar  with  the  operation.  A  thorough 
knowledge  of  the  anatomy  of  the  parts  ;  a  deftness  in  the  ma- 
nipulation of  the  requisite  appliances  ;  a  little  experience  on  a 
cadaver,  and  one  or  two  trained  assistants  are  all  that  are  req- 
uisite. Even  the  most  desperate  cases  have  been  known  to 
recover  through  this  instrumentality,  although  it  must  be  borne 
in  mind  that  cases  requiring  or  seeming  to  require  intubation 
are,  generally  speaking,  cases  that  have  passed  the  local  mani- 
festations of  the  disease,  and  are  suffering  not  only  from  sten- 
osis, but  from  general  blood-poisoning  as  well. 


DIPHTHERIA— HTGIENIC  MANAGEMENT.  369 

When  intubation  fails  we  have  no  confidence  in  tracheotomy 
as  a  last  resort. 

Hygienic  Management. — Much  can  be  done  for  these 
cases  of  diphtheria  in  an  auxiliary  and  hygienic  way.  Chil- 
dren who  are  subject  to  catarrh  or  to  inflammatory  affections  of 
the  throat  should  be  carefully  looked  after  during  epidemics 
of  diphtheria.  It  is  just  this  class  of  children  in  whom,  at 
any  time,  the  disease  may  develop  spontaneously.  Such  per- 
sons should  avoid  crowded  gatherings  where  the  air  is  likely 
to  be  vitiated,  as  theaters,  public  halls,  and  even  churches. 
This  is  especially  important  during  cold  weather,  if  diphtheria 
be  prevalent.  In  case  the  disease  develops  in  a  family  where 
there  are  others  of  susceptible  age,  the  greatest  care  should  be 
taken  to  prevent  its  spread. 

The  diphtheritic  contagium  is  cumulative  and  the  second 
case  in  a  family  is  apt  to  be  worse  than  the  first.  Great  cau- 
tion should  be  used  about  kissing'  and  fondling  a  child  with 
sore  throat,  no  matter  how  innocent  it  may  appear.  Dogs,  cats, 
sheep  and  swine,  all  have  diphtheria,  and,  hence,  are  dangerous 
as  pets,  especially  during  epidemics  of  diphtheria. 

A  person  with  this  disease  should  be  rigidly  isolated.  A 
large  room  on  the  upper  floor  should  be  selected  by  prefer- 
ence, and  with  a  grate  in  it,  if  possible.  A  southern  exposure 
is  to  be  preferred.  Measures  should  be  taken  to  secure  plenty  of 
fresh  air.  The  window  sashes  should  be  open  top  and  bottom, 
and  a  screen  thrown  about  the  bed  to  protect  the  patient  from 
currents  of  air.  In  laryngeal  diphtheria  the  temperature  may 
be  kept  as  high  as  76°  or  80°  Fahr.,  but  in  uncomplicated 
cases  68°  or  70°  is  better.  The  greatest  care  should  be  taken 
to  avoid  disseminating  the  disease  by  fomites.  The  sick  room 
should  be  dismantled,  and  all  unnecessary  furniture,  carpets 
and  hangings  should  be  removed.  Instead  of  handkerchiefs, 
bits  of  old  linen  or  cotton  should  be  used,  and  burned  as  soon 
as  no  longer  needed.  All  earthen  vessels  should  be  frequently 
cleansed  and  disinfected  with  Piatt's  chlorides  or  chloralum. 
Sheets  hung  up  in  the  doorways  and  moistened  occasionally 
with  these  liquids  prevent  the  contagium  from  disseminating 
itself  unnecessarily  abroad. 

The  diet  should  be  of  the  most  concentrated  and  nourishing 
kind,  and  yet  great  care  must  be  taken  not  to  ofl"end  the 
stomach.  Everything  may  depend  on  the  maintenance  of  the 
digestive  powers.  Repugnance  for  foods  is  often  great  and 
unconquerable.  Only  such  foods  should  be  urged  upon  the 
patient  as  are  easily  swallowed,  and  easily  digested.  Milk, 
beef  juice,  Murdock's  food — any  of  these  may  be  given,  and  in 
D.C.— 24 


^70  THE  DISEASES  OF  CHILDREN. 

case  of  stomach  intolerance  the  rectum  should  be  used.     The 
rule  for  feeding  should  be  little  and  often. 

If  stimulants  are  used,  they  should  be  given  with  great 
regularity  and  system.  During  convalescence  great  care  must 
be  used  to  avoid  over-exertion  or  exercise  that  would  tend  to 
excite  undue  action  of  the  heart. 


CHAPTER  II. 

WHOOPING  COUGH   (PERTUSSIS;   TUSSIS  CONVULSIVA). 

Definition. — Whooping  cough  is  an  acute  disease  of  the  air 
passages,  having  a  specific  contagium,  and  is  inclined  to  be 
epidemic  in  character.  It  is  distinctively  a  disease  of  childhood, 
and  its  chief  characteristic  is  the  spasmodic  cough,  which,  in 
typical  cases,  comes  in  paroxysms  and  is  terminated  by  a  long- 
drawn,  audible  inspiration,  called  the  "whoop" — hence  the 
name.  It  is  a  disease  of  most  ancient  date  and  of  the  highest 
respectability,  so  far  as  its  democratic  tendencies  are  concerned. 
It  is  one  of  the  few  diseases  that  are  not  attributed  to  filth. 
Its  cause  is  unknown.  It  has  been  regarded  as  an  affection  of 
the  stomach,  as  a  species  of  catarrh,  as  a  neurosis.  There  are 
those  whose  temerity  is  such,  that  they  do  not  scruple  to  regard 
it  as  of  microbic  origin.  The  '^'^  bacillus  tussis  convulsive''  has 
been  isolated,  cultivated  and  classified.  And  yet  the  latest 
writer  on  the  disease,*  says,  speaking  of  the  various  untenable 
theories  held  prior  to  the  beginning  of  the  present  century : 
**  The  lapse  of  nearly  a  century  has  not  entirely  cleared  up 
these  obscurities  as  to  nature  and  cause,  nor  relieved  the  prac- 
tice of  medicine  of  the  odium  of  polypharmacy  in  treatment." 

The  latest  researches  in  pathology  indicate  that  it  has  no 
morbid  anatomy  except  in  its  complications.  One  attack  con- 
fers as  much  immunity  on  its  victims  as  does  scarlatina  or 
variola  on  theirs — perhaps  more  so.  Sucklings  are  immune. 
Its  principal  victims  are  between  six  months  and  six  years  of 
age — most  of  them  under  four.  For  some  inexplicable  reason, 
the  female  sex  suffers  most,  in  the  proportion,  according  to 
nearly  all  authors,  of  5  to  4.  Girls  also  suffer  more  severely  than 
boys.  Measles  and  pregnancy  predispose  to  it.  It  is  prevalent 
at  all  seasons  of  the  year,  but  more  so  during  the  autumn  and 
spring. 

Symptoms. — For  clinical  study,  the  disease  may  be  conven- 
iently divided  into  stages.  Thus:  1st,  catarrhal;  2d,  spasmod- 
ic or  convulsive;  3d,  remission  or  decline.  The  first  and  third 
stages  are  oftentimes  but  poorly  defined — the  former  especially 
so.     The  middle  or  convulsive  stage  is  also  frequently  wanting 


♦  Dr.  James  L.  Whittaker  in  Pepper's  "  Text  Book,"  etc. 

(371) 


S72  THE  DISEASES  OF  CHILDREN. 

in  positive  characteristics,  no  definite  "  whoop  "  being  manifest. 
During  the  first  or  catarrhal  stage,  there  are  no  special  symp- 
toms that  distinguish  it  from  an  ordinary  cold.  The  spasmodic 
character  of  the  cough  is  usually  not  developed  until  later,  and 
all  that  can  be  discovered  in  the  average  subject  is  a  cough  of 
catarrhal  character;  but  this  cough  does  not  yield  to  remedies 
like  that  which  comes  from  an  ordinary  cold.  It  persists  in 
spite  of  well-chosen  and  ordinarily  successful  remedies.  In 
many  cases,  however,  the  symptoms  are  more  pronounced,  and 
it  is  noticeable  that  the  cough  is  easily  excited  by  swallowing 
anything  of  a  dry  nature,  such  as  crackers  or  dry  bread — any- 
thing, in  fact,  that  irritates  the  throat.  It  is  also  noticeable 
that  the  cough  is  inclined  to  be  paroxysmal,  especially  at  night ; 
the  eyes  are  somewhat  puffy,  and  the  face  takes  on  a  swollen 
and  sallow  look,  as  if  there  were  some  deeper-seated  trouble 
than  should  come  from  a  transient  and  trifling  cause.  An 
examination  of  the  chest  during  this  first  stage  sheds  but  little 
light  upon  the  true  nature  of  the  disease.  Some  bronchial 
rales  may  be  heard  by  aid  of  the  stethoscope,  but  no  more  than 
are  heard  in  the  incipiency  of  the  mildest  bronchitis.  As  the 
disease  progresses,  however,  the  symptoms  become  more  pro- 
nounced ;  the  cough  becomes  gradually  more  paroxysmal,  and 
at  the  termination  of  each  paroxysm,  there  is  an  expulsion  of 
phlegm  from  the  bronchi,  often  accompanied  with  vomiting  or 
gagging.  As  with  other  febrile  conditions,  the  child  may  be 
pretty  well  during  the  day,  with  good  appetite  and  little 
indication  of  sickness;  or,  on  the  other  hand,  there  may 
be  considerable  fever,  accompanied  with  fits  of  coughing 
and  fretfulness  and  loss  of  appetite.  Even  now  there  are 
nocturnal  exacerbations.  While  quietly  sleeping  there 
will  be  a  sudden  onset  of  cough,  more  or  less  severe,  but 
always  enough  to  awaken  the  patient  and  prevent  continu- 
ous slumber.  Auscultation  during  the  first  stage,  as  already 
stated,  may  reveal  a  slight  bronchitis  or  bronchial  catarrh  affect- 
ing the  larger  tubes  ;  but,  as  a  rule,  the  cough  and  the  general 
symptoms  of  ill-health  are  out  of  all  proportion  to  the  physical 
signs.  During  the  day  the  patient  is  up  and  dressed,  but  be- 
comes restless  and  anxious  just  before  a  paroxysm  of  cough 
approaches.  The  child  early  learns  to  dread  these  paroxysms, 
and  as  soon  as  one  is  felt  to  be  approaching  he  instinctively 
runs  to  his  nurse  or  mother  for  support.  In  their  absence,  he 
seizes  the  nearest  thing  to  him,  be  it  chair  or  table,  and  clings 
to  it  tenaciously  until  the  paroxysm  is  over.  The  duration  of 
these  seizures  is  various,  lasting  from  a  quarter  of  a  minute  to 
a  minute  or  more.  In  typical  cases  the  cough  is  attended  with 
flushing  of  the  face  and  suffusion  of  the  eyes,  and  each  par- 


WHOOPING  COUGH— DEFINITION.  BTB 

oxysm  is  accompanied  with  vomiting.  During  the  catarrhal 
stage  there  is  commonly  more  or  less  fever ;  but  many  cases 
run  their  course  from  beginning  to  end  with  no  perceptible  rise 
in  temperature.  When  fever  exists,  it  is  most  noticeable  at 
bed-time,  and  the  cough  is  strongly  inclined  to  exhibit  its 
peculiarities  at  night.  It  arouses  the  child  from  the  profound- 
est  slumber,  into  which  he  relapses  again  as  soon  as  the  par- 
oxysm is  over.  The  different  stages  of  the  disease  are  exceed- 
ingly variable  in  duration.  Sometimes  the  first  or  catarrhal 
stage  lasts  but  a  few  days,  while  in  other  cases  it  may  last  for 
weeks.  The  stage  of  decline  is  especially  indefinite.  An  at- 
tack beginning  in  the  fall  or  early  winter  is  pretty  sure  to  last 
until  the  following  spring  or  summer.  The  cough  is  greatly 
aggravated  by  breathing  cold  air,  and  sensitiveness  to  cold 
remains  with  the  subjects  of  whooping  cough  for  months 
after  the  disease  is  apparently  over.  In  the  middle  or  convul- 
sive stage  the  neurotic  element  asserts  itself  and  is  more  or 
less  pronounced.  The  seizures  are  sudden,  and  yet  the  child 
is  prone  to  feel  a  premonition  of  its  approach — a  sort  of  aura 
which  previous  experience  has  rendered  recognizable.  It  is  a 
sense  of  impending  danger,  or  feehng  of  distress,  which  impels 
the  victim  to  leave  its  play  or  study  or  meal,  as  the  case  may 
be,  and  seek  the  most  available  succor.  Thereupon  ensues  the 
series  of  expiratory  coughs  that  distinguishes  the  disease  from 
all  other  affections  of  the  respiratory  organs.  Goodheart  likens 
it  to  the  attack  which  one  experiences  when,  in  swallowing 
liquids,  a  drop  or  two  gets  into  the  rima  glottidis.  There  is 
the  same  sudden  onset  of  a  number  of  rapidly  succeeding  ex- 
piratory coughs,  till  the  face  becomes  turgid  and  the  eyeballs 
start  from  their  sockets  and  the  eyes  run  over  with  tears. 
There  is  frequently  at  the  termination  of  such  an  attack  the 
semblance  of  a  whoop  or  a  crow,  which  is  due  to  the  rapid 
influx  of  air  to  satisfy  the  respiratory  needs,  which  have  become 
urgent  by  reason  of  the  successive  and  exhaustive  expiratory 
efforts. 

The  paroxysms  occur  in  every  grade  of  frequency  and  sever- 
ity. They  are  often  so  mild  as  to  lose  all  distinctive  character- 
istics, and  in  other  cases  are  so  severe  as  to  cause  rupture  of 
blood-vessels.  Hemorrhages  often  occur  from  nose  and  mouth. 
It  is  not  at  all  uncommon  for  subconjunctival  hemorrhages  to 
occur.  The  membrana  tympani  occasionally  ruptures  and  is 
accompanied  by  bleeding  from  the  external  meatus.  We  have 
a  case  now  under  observation  where  hemorrhage  occurred  in 
the  brain,  producing  catalepsy.  This  accident  happened  some 
five  years  ago,  when  the  child  was  two  years  old.  Hernia  is 
not    uncommon,    nor    prolapsus    ani.     Convulsions    are    also 


374  THE  DISEASES  OF  CHILDREN. 

possible.  The  frequency  of  the  paroxysmal  attacks  of  cough 
varies  all  the  way  from  ten  or  twelve  daily,  to  double  or  quad- 
ruple this  number.  The  severity  of  the  disease  is  in  direct 
ratio  to  the  number  and  intensity  of  the  paroxysms.  Dur- 
ing the  intervals  between  paroxysms,  the  child  is  to  all  appear- 
ances in  perfect  health.  Even  when  the  attacks  of  coughing 
are  frequent  at  night,  arousing  the  child  from  profound  slumber 
at  short  intervals  and  causing  it  to  struggle  fiercely  for  air,  it 
falls  asleep  again  immediately  the  attack  is  over,  and  awakens 
in  the  morning  without  a  sign  of  fatigue. 

The  expulsion  of  a  quantity  of  ropy,  tenacious  mucus  at  the 
end  of  each  paroxysm  of  coughing  is  an  essential  feature  of  the 
disease. 

A  curious  symptom  is  present  in  the  great  majority  of  severe 
cases,  but  is  incidental  rather  than  essential  to  the  disease 
proper.  It  consists  in  the  appearance  of  an  ulcer  on  the  fre- 
num  linguae.  This  lesion  was  observed  so  constantly  as  to  give 
rise  to  the  belief  that  it  had  a  causal  relation  to  the  disease  ; 
but  it  is  now  known  that  it  is  caused  by  the  friction  of  the  pro- 
truded tongue  against  the  inferior  incisors.  It  is  never  observed 
in  cases  that  occur  in  children  prior  to  dentition. 

The  paroxysmal  stage  lasts  as  a  rule  from  one  to  four  weeks, 
when  the  interval  between  paroxysms  becomes  gradually  longer 
and  the  explosions  themselves  less  severe  and  prolonged. 
During  the  stage  of  decline,  however,  there  may  be  occasional 
paroxysms  of  former  severity,  and  it  is  no  uncommon  thing  for 
these  explosions  to  recur  with  such  original  intensity  and  fre- 
quency as  to  seem  like  a  veritable  relapse.  In  this  way  this 
third  stage  of  the  disease  is  often  greatly  prolonged,  lasting 
sometimes  as  long  as  a  month  or  more.  There  are  cases  in 
which  the  patient  is  said  never  to  have  recovered  from  the  dis- 
ease. But  when  cases  like  these  are  unduly  prolonged,  it  is 
doubtless  due  to  complications  to  be  spoken  of  hereafter,  such 
as  chronic  bronchitis,  bronchiectasis  or  tuberculosis. 

It  is  worthy  of  note  that  all  during  the  course  of  the  disease 
any  excitement,  such  as  anger  or  boisterous  play,  is  sure  to 
precipitate  a  paroxysm  of  cough  and  intensify  its  severity. 

Complications. — Whooping  cough  is  liable  to  innumerable 
complications,  and  these  constitute  the  really  dangerous  ele- 
ment in  the  disease.  There  is  always  more  or  less  bron- 
chitis from  the  first,  and  the  rales  which  accompany  bron- 
chitis are  usually  so  pronounced  that  they  drown  all  other 
respiratory  sounds.  Any  disease  attended  with  bronchitis  is 
also  liable  to  broncho-pneumonia,  and  hence  the  latter  is  by 
far  the  most  frequent  of  the  serious  complications  of  whooping 
cough. 


WHOOPING  COUGH— DIAGNOSIS.  375 

Convulsions,  usually  of  a  clonic  character,  are  very  apt  to 
complicate  the  disease,  from  the  congestion  of  the  cerebral 
veins  and  sinuses,  produced  by  the  explosive  force  of  the  cough. 
These  convulsions,  affecting  for  the  most  part  the  external 
muscles,  occur  most  frequently  during  the  second  stage  of  the 
disease,  when  the  cough  is  most  severe,  and  in  infancy  more 
often  than  in  childhood.  As  stated  by  J.  Lewis  Smith,  the 
gravity  of  the  convulsive  attack  can  be  ascertained  by  observ- 
ing whether  or  not  the  patient  readily  recovers  consciousness. 
Its  return  indicates  that  there  is  no  serious  congestion.  On 
the  other  hand,  great  and  persistent  drowsiness,  or  a  semi- 
comatose condition,  indicates  profound  congestion,  and  perhaps 
even  the  formation  of  clots  in  the  sinuses  of  the  brain.  Death 
from  convulsions  is  usually  preceded  by  coma. 

The  spasmodic  closure  of  the  glottis,  and  the  powerful  efforts 
of  the  expiratory  muscles,  sometimes  develop  edema  of  the 
glottis,  and  sometimes — perhaps  more  frequently — emphysema 
of  the  lungs.  When  the  latter  occurs,  it  is  usually  slight,  mar- 
ginal or  peripheral,  and  is  marked  by  dilatation  only  of  the 
air-cells.  Occasionally  the  dividing  walls  are  broken,  and  the 
air-cells  are  ruptured,  and  a  pneumothorax  developed. 

Vomiting,  which  is  an  almost  universal  accompaniment  of 
severe,  or  even  well-marked  cases,  may  be  so  severe  and  per- 
sistent as  to  constitute  a  true  complication.  It  may  result  in 
marasmus,  or  be  so  severe,  lasting  into  the  intervals,  as  to  cause 
collapse.  Complications  on  the  part  of  the  nervous  system 
are  rare.  Occasionally  a  paroxysm  is  followed  by  strabismus, 
dilatation  of  pupils,  or  blindness. 

Diagnosis. — Whooping  cough,  as  already  stated,  occurs  in 
paroxysms  or  explosions.  The  series  of  expiratory  coughs, 
terminating  in  an  audible  inspiration  and  the  expulsion  of 
phlegm  and  mucus  from  the  mouth ;  the  anxiety  shown  by 
the  patient  whenever  a  paroxysm  is  impending  ;  the  puffy  eye- 
lids ;  the  sallow,  pallid  countenance ;  the  tendency  of  the 
cough  to  group  itself  into  paroxysms  ;  the  aggravation  of  the 
cough  at  night  and  by  eating  any  dry  food  ;  the  attendant 
tendency  to  vomit  with  the  cough — when  these  symptoms  or 
many  of  them  are  present,  there  is  no  difficulty  in  establishing 
the  diagnosis. 

During  the  first  stage,  if  the  history  of  exposure  be  obscure, 
the  diagnosis  is  often  in  doubt,  and  in  mild  cases  must  remain 
so  until  the  characteristic  whoop  is  developed.  Even  now 
there  are  grounds  for  confusion.  It  is  allowed  by  all  writers 
that  chronic  diseases  of  the  bronchial  glands  sometimes  pro- 
duce a  noisy,  paroxysmal  cough,  very  like  pertussis.  But  in 
such  cases  there  is  an  absence  of  any  definite  stages  and  they 


376  THE  DISEASES  OF  CHILDREN. 

occur  sporadically,  not  in  epidemics.  There  is  evidence  of 
associated  lung  disease,  and  a  history  of  wasting,  long  before 
the  development  of  the  cough. 

Prognosis. — The  prognosis  in  whooping  cough  depends 
somewhat  upon  age  and  constitution,  but  more  upon  treatment 
and  management.  It  seems  strange  to  read  in  the  works  of 
late  authors  that  this  affection  has  ever  had  so  large  a  mortality 
as  is  therein  mentioned.  Thus,  it  is  stated  by  Dr.  Whittaker 
that  out  of  5CX),34i  deaths  occurring  in  England  in  one  year, 
10,318  deaths  were  from  whooping  cough.  Again,  he  states 
that  in  one  decade  in  New  York,  wherein  4,062  deaths  occurred 
from  typhoid  fever,  there  were  4,094  deaths  from  this  disease. 
In  this  city  (Chicago),  during  1892  there  were  1,489  deaths 
from  typhoid  fever  and  164  deaths  from  whooping  cough. 
This  year,  however,  is  not  a  fair  criterion  by  which  to  judge  of 
the  relative  mortality  from  the  two  diseases.  Typhoid  was 
very  prevalent  and  unusually  fatal,  while  whooping  cough  was 
mild  in  its  attacks  and  not  very  prevalent. 

That  it  is  not  a  trifling  ailment  is  shown  by  the  relative 
mortality  from  it,  as  compared  with  scarlet  fever  and  measles. 
The  mortality  from  the  three  diseases  was  (1892)  as  follows: 
Scarlet  fever,  382;  measles,  185  ;  whooping  cough,  164.  Un- 
der homeopathic  treatment,  this  disease  usually  runs  a  mild, 
although  sometimes  tedious,  course,  and  its  complications  and 
sequelae  are  neither  common  nor  severe.  This  is  especially 
true  if  the  cases  affected  with  some  dyscrasia,  be  eliminated 
from  our  statistics. 

The  greatest  mortality  is  always  in  young  infants.  In  chil- 
dren of  four  or  five  years  of  age,  the  mortality  is  small.  Biermer 
made  a  grand  average  of  the  established  mortality  rate,  based 
upon  the  statistics  of  many  authors,  at  ^.6  per  cent. 

The  most  frequent  causes  of  death  are  suffocation  due  to- 
spasm  of  the  glottis,  broncho-pneumonia,  hemorrhages  and 
marasmus.  The  more  numerous  the  seizures  in  the  twenty- 
four  hours,  the  more  grave  is  the  disease.  When  they  reach 
as  high  as  fifty  or  sixty  paroxysms  in  a  day,  the  disease 
assumes  a  special  gravity. 

Treatment. — There  is  no  remedy  in  our  own  or  any  other 
school  of  practice  which  acts  as  a  prophylactic  in  whooping 
cough.  Nor  is  there  any  remedy  that  can  properly  be  regarded 
as  a  specific  in  the  affection.  The  treatment  to  be  successful 
must  be  symptomatic,  and  regard  must  be  had  for  the  genius 
epidenticus.  In  some  epidemics  a  remedy  may  frequently  be 
found  that  will  abort  some  cases,  abbreviate  others,  and  amel- 
iorate all.  Thus,  Dr.  Winterburn  states  that  in  a  widespread 
epidemic,    occurring   in    Brooklyn    some  years   ago,    he    used 


WHOOPING  COUGH— TREATMENT.  377 

gelsemium  almost  exclusively,  and  with  the  most  satisfactory 
results. 

This  drug  is  a  prince  among  nervous  and  especially  spas- 
modic affections,  and  ought,  a  priori,  to  be  a  useful  remedy  in 
the  spasmodic  stage  of  the  disease  at  all  times ;  and  yet  we 
have  failed  to  find  it  mentioned  in  connection  with  whooping 
cough  by  any  author  whom  we  have  consulted.  Dr.  W.  A. 
Edmonds,  of  St.  Louis,  in  his  "Treatise  on  Diseases  of  Chil- 
dren," says  that  in  the  early  years  of  his  practice  he  achieved 
considerable  local  reputation  by  using  belladonna  and  drosera^ 
either  simultaneously  or  in  combination.  He  says :  "  The  form 
of  combination  was  to  medicate  pellets  No.  25  with  ist  deci- 
mal dilutions  of  the  two  named  remedies,  and  prescribe  two  to 
four,  six,  or  eight  pellets,  according  to  the  age  of  the  child,  at 
intervals  of  about  two  hours  at  first,  and  when  better  every 
three  or  four  hours.  .  .  .  This  prescription,"  he  further 
states,  "  I  have  found  remarkably  successful  in  the  treatment 
of  whooping  cough.  Sometimes  it  has  seemed  to  cut  it  short ; 
it  rarely  fails  to  induce  a  most  comfortable  palliation." 

We  have,  ourselves,  used,  with  great  satisfaction,  a  similar 
combination  of  ipecac  and  hyoscyamus,  and  we  feel  sure  that  we 
have  many  times  aborted  an  attack  of  whooping  cough  by 
their  combined  use  in  the  manner  above  indicated.  Probably 
a  more  scientific  and  perhaps  more  successful  method  would 
be  to  give  the  belladonna  or  the  hyoscyamus  in  the  febrile  or 
catarrhal  stage,  and  the  drosera  or  ipecac  afterwards.  The  use 
of  remedies  during  a  paroxysm  is  out  of  the  question.  What- 
ever therapeutic  measures  are  adopted,  they  must  be  brought 
into  use  during  the  intervals,  and  must  be  used  persistently 
and  patiently  in  order  to  test  their  utility.  In  addition  to  the 
remedies  to  be  considered  hereafter,  according  to  their  symp- 
tomatology, various  inhalents  have  been  used,  and  apparently 
with  some  degree  of  success.  Among  the  more  prominent  of 
these  are  turpentine,  thymol,  carbolic  acid,  cocaine,  tar,  benzole, 
sulphuretted  hydrogen,  and  illuminating  gas  (carburetted  hy- 
drogen). Vapo-cresolene,  which  is  one  of  the  products  of  coal- 
tar,  has  considerable  repute,  and  we  have  sometimes  thought 
that  it  did  ameliorate  the  paroxysms ;  but  we  have  been  unable 
to  discover  any  permanent  good  from  any  of  these  volatile 
remedies.  On  the  other  hand,  they  are  open  to  serious  objec- 
tions— at  least,  many  of  them  are — because  they  fill  the  air 
with  pungent  fumes,  that  make  it  almost  intolerable  for  the 
attendants,  and  must  of  necessity  vitiate  the  air  breathed  by 
the  patient. 

In  lack  of  indubitable  evidence  of  merit  in  the  use  of  such 
malodorous  compounds,  it  is  better  to  give  the  child  plenty  of 


878  THE  DISEASES  OF  CHILDREN. 

fresh  air  to  breathe,  and  trust  the  rest  to  nature  and  remedies 
internally  administered. 

Therapeutics. — In  addition  to  the  drugs  already  mentioned, 
there  is  a  long  list  of  remedies  whose  homeopathicity  to.  cer- 
tain phases  of  the  disease  is  vouched  for  by  unquestionable 
authority.  Raue,  in  his  "  Special  Pathology  and  Therapeutic 
Hints,"  gives  the  symptomatology  of  over  seventy  drugs. 
Lilienthal  contents  himself  with  thirty-four.  We  shall  limit 
ourselves  to  a  half-dozen  or  so  of  the  principal  remedies,  which 
have  received  personal  verification  of  their  therapeutic  value. 

As  regards  the  complications  and  their  treatment  the  reader 
is  referred  to  the  special  chapter  or  section  bearing  upon  the 
disorders,  regardless  of  their  origin.  There  is  no  special  reason 
why  bronchitis,  broncho-pneumonia,  or  convulsions  should  be 
treated  differently  when  arising  in  the  course  of  whooping 
cough  than  if  they  arose  idiopathically,  and  we  thus  avoid 
needless  repetition. 

Belladonna. — Cough  so  spasmodic  that  patient  cries ;  great 
congestion  of  head  and  face,  which  causes  considerable  coryza 
and  epistaxis ;  short,  rough,  hollow  cough,  caused  by  tickling 
sensation  in  larynx ;  dry,  spasmodic  cough,  worse  at  night  ; 
touching  the  throat  or  moving  it  excites  the  cough  ;  the  breath- 
ing is  short,  hurried  and  labored  ;  dyspnea  ;  involuntary  passage 
of  stools. 

Corallium  Rubrum. — Paroxysms  of  convulsive  coughing  ; 
cough  excited  by  deep  inspiration  ;  rapid  succession  of  violent 
paroxysms  of  coughing,  so  violent  that  child  stops  breathing, 
grows  purple  in  the  face,  and  becomes  exhausted,  followed  by 
vomiting  of  large  quantities  of  thick,  tough  mucus ;  paroxysms 
increase  in  frequency  towards  evening. 

Cuprum  Met. — Most  useful  action  is  in  the  spasmodic  stage ; 
face  and  lips  dark  blue,  almost  black ;  expectoration  of  blood- 
tinged,  putrid  mucus,  especially  in  morning ;  cough  caused  by 
mucus  in  the  trachea  ;  cough  occurs  in  paroxysms  which  are 
violent  and  long  lasting ;  paroxysms  so  long  that  child  loses  its 
breath,  and  is  thrown  into  convulsions  with  purple  or  black 
face ;  cough  aggravated  by  eating  solid  food,  but  liquids  amel- 
iorate the  paroxysms. 

Drosera — The  paroxysms  of  coughing  follow  each  other  so 
quickly  that  child  cannot  get  his  breath  ;  cough  causes  a  feeling 
of  constriction  in  the  chest,  which  is  relieved  by  pressing  on 
the  stomach  ;  cough  is  worse  after  midnight  and  is  followed  by 
retching  and  vomiting,  and  cold  clammy  perspiration  ;  epistaxis 
frequently  follows  the  paroxysms  of  coughing. 

Gelsemium — Paroxysms  of  hoarseness  and  coughing  from 
tickling  and  dry  roughness  of  the   fauces;  severe,  convulsive, 


WHOOPING  COUGH— TREATMENT.  379 

spasmodic  cough  ;  soreness  of  the  chest  when  coughing  ;  heavy 
and  labored  respirations ;  expirations  sudden  and  forcible. — 
E.  M.  Hale. 

Hyoscyamus. — Constriction  in  throat  causing  difificult  swallow- 
ing, especially  of  liquids  ;  great  thirst,  but  drinks  little  at  a 
time  ;  at  night  the  cough  is  dry  and  spasmodic,  aggravated  by 
lying  down,  and  better  when  sitting  up ;  face  dark  red,  bloated 
and  distorted. 

Ipecac. — Aversion  to  food  of  all  kinds,  with  vomiting  of  food 
and  some  bile  ;  peevish  and  irritable,  with  face  dark  and  anxious 
looking ;  urine  scanty  and  bloody  ;  breathing  difficult,  with  rat- 
tling in  chest  and  expectoration  of  bloody  mucus ;  cough  brings 
on  a  vomiting  spell,  with  difficult  breathing  and  epistaxis  of 
bright-red  blood ;  cough  worse  at  night,  with  copious  hemor- 
rhages from  nose  and  mouth  ;  dyspnea ;  face  blue  and  body 
rigid. 

Stipp,  of  Nuremburg,  has  recently  introduced  to  the  therapy 
of  the  old  school  a  new  remedy,  which  is  by  many  believed  to 
be  almost  a  specific  for  this  disease.  It  is  bromoform.  It  is 
used  safely,  so  it  is  said,  in  doses  of  from  one  to  five  drops, 
according  to  age,  repeated  three  or  four  times  daily.  In  large 
doses  it  has  produced  narcosis.  In  Senator's  polyclinic  one 
hundred  cases  were  treated  by  Lilienthal,  who  claims  that  it 
rendered  the  cases  milder  in  the  course  of  a  few  days.  A  New 
York  physician,  who  treated  fi-fty-one  cases  with  it,  claimed  that 
it  surpassed  all  other  remedies  in  its  curative  properties.  The 
duration  of  the  treatment  was  from  ten  to  thirty  days ;  and 
cure  occurred  in  75  per  cent,  of  the  cases  in  from  two  to  three 
weeks,  "  if  there  were  no  complications." 

Hygienic  Treatment. — A  child  with  whooping  cough  should 
be  kept  indoors  in  inclement  weather,  and  allowed  proper 
freedom  to  enjoy  the  fresh  air  in  mild  and  suitable  weather. 
The  clothing  should  be  of  woolen ;  the  diet  should  be  of  the 
most  wholesome  and  concentrated  character  consistent  with  good 
digestion.  It  must  not  be  forgotten  that  much  aliment  is  lost 
through  vomiting  in  bad  cases,  and  marasmus  is  one  of  the  for- 
midable sequelae.  Meat  broths,  milk,  and  eggs — the  latter,  of 
course,  in  older  children — are  the  best  articles  of  diet.  In  slow 
convalescence,  change  of  climate  often  works  wonders.  The 
temperature  of  the  house  or  the  rooms  of  a  whooping-cough 
patient  may  be  kept  warmer  than  would  be  advisable  in  most 
other  affections ;  70°  or  72°  is  none  too  warm,  but  a  uniform 
temperature  in  this  disease  is  very  desirable. 


CHAPTER  III. 

PAROTIDITIS  (PAROTITIS;   MUMPS). 

Definition. — Mumps  is  an  acute  and  painful  inflammation  of 
the  parotid  glands.  It  is  contagious,  but  not  infectious.  It  is  of 
brief  duration,  and  but  little  gravity,  except  as  it  involves  other 
and  remote  organs.  It  is  inclined  to  be  epidemic.  A  similar, 
although  probably  not  identical,  inflammation  of  the  parotids, 
is  of  frequent  occurrence  in  the  course  of  typhus,  typhoid  and 
septic  fevers  ;  but  in  the  latter  cases  suppuration  of  the  glands 
is  apt  to  supervene,  which  is  not  true  of  mumps  proper.  It 
is  very  prone  to  precede  or  follow  outbreaks  of  the  exanthemata, 
and  there  is  rarely  an  epidemic  of  any  of  the  diseases  of  child- 
hood, without  some  cases  of  mumps.  It  is  mentioned  by  all 
of  the  older  medical  writers,  and  is,  without  doubt,  a  disease  of 
great  antiquity.  It  is  most  prevalent  in  the  first  quarter  of 
the  year,  and  affects  males  more  frequently  than  females. 

The  two  extremes  of  life  are  practically  exempt.  The  period 
showing  the  greatest  susceptibility  is  from  two  to  ten  years.  It 
is  very  apt  to  prevail  epidemically  where  a  considerable  num- 
ber of  people  are  herded  together.  Thus,  boarding-schools, 
jails,  orphan  asylums,  and  especially  barracks,  are  often  in- 
vaded, and  when  this  is  the  case  it  is  pretty  sure  to  affect  all 
who  have  not  had  it  previously.  One  attack,  if  bilateral,  affords 
security  from  further  infection.  The  disease  sometimes  attacks 
the  lower  animals,  especially  dogs ;  and  it  is  possible  that  it 
may  be  by  them  communicated  back  to  man,  and  the  spread  of 
the  contagium  be  thus  promoted.  Poore  declares  that  *'  a  boy 
aged  seventeen,  affected  with  mumps,  and  five  days  later  with 
inflammation  of  the  testicle,  which  suffered  atrophy,  communi- 
cated the  disease  to  a  dog,  his  constant  companion  and  bed- 
fellow. The  dog  began  to  show  symptoms  in  fourteen  days 
exactly  like  those  of  his  master,  including  subsequent  involve- 
ment of  the  testicles,  which  likewise  suffered  atrophy.  Thence- 
forth the  dog  took  no  pleasure  in  the  society  of  other  dogs, 
which  he  seemed  to  shun,  and  in  his  disgust  forsook  his  old 
master  for  a  new  one."* 

Pure  mumps  has  no  definite  lesion  and  no  morbid  anatomy, 

*  Pepper's  "  Text  Book,"  p.  305. 

(380) 


PAROTIDITIS— SYMPTOMS.  381 

except  a  tuansient  hyperemia,  which  subsides  during  resolution, 
leaving  no  trace  behind.  It  is  liable,  however,  to  affect  neigh- 
boring glands,  and  the  connective  tissue  between  and  around 
them.  The  total  duration  of  parotiditis  is,  in  mild  cases,  from 
five  to  seven  days,  and  in  others  it  may  last  double  this  length 
of  time.     Rarely,  but  sometimes,  the  tonsils  are  also  tumefied. 

Symptoms. — Ordinary  mumps  has  no  premonitory  or  pro- 
dromal stage.  It  commences  with  tenderness  in  the  parotid 
region,  followed  soon  after  by  tumefaction,  which  gradually 
increases  until  it  fills  the  depression  under  the  ear  and  extends 
forward  and  upward  into  the  cheek,  and  downward  to  a  greater 
or  less  extent  upon  the  neck.  As  a  rule  the  color  of  the  skin 
is  unaltered,  but  occasionally  there  may  be  some  redness  over 
the  parotid.  There  is  a  dull,  aching  pain  whenever  the  mastica- 
tory muscles  are  used  ;  hence,  anything  which  excites  an  unu- 
sual flow  of  saliva,  like  acids,  is  attended  by  increased  discomfort. 
The  disease  is  attended  with  considerable  malaise  rather  than 
downright  illness.  In  many  cases  the  temperature  remains 
normal  although  it  sometimes  rises  as  high  as  102°  or  even 
higher. 

The  swelling  reaches  its  maximum  from  the  third  to  the 
sixth  day.  At  this  time,  the  most  prominent  point  is  immedi- 
ately under  the  lobe  of  the  ear  which  it  presses  upward  and 
outward.  The  tumor  which  is  formed  is  firm,  but  elastic,  and 
has  a  doughy  feel,  very  different  from  the  hard  and  unyielding 
character  of  an  induration. 

Not  only  is  mastication  painful  when  the  disease  is  at  its 
height  but  talking  is  attended  with  difficulty,  causing  the 
patient  to  mumble.  This  is  supposed  to  have  given  origin  to 
the  name  under  which  the  affection  is  most  commonly  known. 

In  most  cases  parotiditis  is  double  ;  it  commences  on  one 
side,  more  often  the  left  than  right,  and  in  from  one  to  four 
days  the  opposite  gland  is  involved.  In  those  exceptional 
cases  in  which  only  one  gland  is  affected,  the  opposite  one 
may  be  the  seat  of  the  disease  at  some  subsequent  period. 
The  proportion  of  cases  in  which  only  one  parotid  is  affected, 
as  compared  with  those  in  which  both  are  involved,  is  stated 
to  be  as  one  to  ten. 

Occasionally  in  double  mumps,  the  swelling  is  so  great  as 
to  extend  from  one  side  to  the  other  in  a  huge,  continuous 
double  chin. 

Complications. — The  chief  danger  in  mumps  arises  from  the 
fact  that  the  swelling  of  the  parotids  sometimes  abates  sud- 
denly, and  coincidently,  in  the  male,  the  testicle,  epididymis  and 
tunica  vaginalis  become  inflamed ;  while  in  the  female,  the 
mammary  glands,  ovaries,  or  the  labia  majora  are  the  seat  of 


382  THE  DISEASES  OF  CHILDREN. 

the  so-called  metastasis.  These  metastatic  inflammations  are 
more  common  about  the  age  of  puberty  than  they  are  either 
earlier  or  later.  Occasionally  they  occur  without  the  usual 
subsidence  of  the  parotid  swelling.  The  period  when  this 
complication  is  most  likely  to  arise  is  uncertain.  Dr.  Dake  re- 
cords twelve  cases  in  which  the  orchitis  began  on  the  seventh 
day  in  six  cases  ;  on  the  eighth  day  in  four,  and  one  each  on  the 
ninth  and  first. 

The  orchitis  usually  subsides  within  a  few  days,  but  in 
exceptional  cases  it  may  lead  to  persistent  hydrocele  and  atro- 
phy of  the  testis.  Whenever  the  disease  is  thus  complicated 
there  is  a  sudden  rise  in  the  temperature,  and  usually  rigors  are 
present.  The  constitutional  disturbance  may  be  severe,  and 
the  high  fever  may  be  attended  with  delirium. 

Meningitis  is  another  complication  which  is  said  to  occur  in 
the  course  of  mumps,  but  it  must  be  very  rare,  as  most  writers 
do  not  mention  it.     We  have  never  seen  it  in  this  connection. 

Diagnosis. — The  only  affection  with  which  parotiditis  is 
likely  to  be  confused  is  that  symptomatic  inflammation  of  the 
glands  which  is  liable  to  occur  in  diphtheria,  scarlet  fever,  or 
some  other  of  the  essential  fevers.  But  in  the  latter  case  the 
swelling  is  hard  like  cartilage ;  is  circumscribed,  and  does  not 
invest  the  ear ;  the  swelling  is  red  instead  of  waxy,  and  there  is 
a  manifest  tendency  to  suppuration,  which  is  not  the  case  in 
true  mumps.  It  should  be  remembered,  however,  that  essen- 
tial mumps  may  involve  the  submaxillary  or  even  the  cervical 
lymphatic  glands  and  leave  the  parotids  untouched.  While 
such  cases  are  exceedingly  rare,  it  is  well  to  bear  the  fact  in 
mind,  in  order  not  to  make  a  mistake. 

Treatment. — In  ordinary  cases  the  treatment  is  exceedingly 
simple  and  consists  principally  in  hygienic  meaures,  which  may 
conduce  to  the  comfort  of  the  patient,  and  the  avoidance  of 
cold,  which  might  tend  to  compHcations.  The  diet  should  con- 
form to  the  patient's  inability  to  masticate,  and  consist  of 
broths,  milk  or  other  easily  digested  liquids  or  semi-solids. 
Soothing  embrocations  may  be  made  to  the  swollen  glands,  to 
alleviate  the  pain  and  tenderness  of  the  parts.  Nothing  should 
be  used,  however,  of  a  repellant  character,  nor  should  the  neck 
be  swathed  too  warmly  with  either  wool  or  cotton.  In  case 
there  is  considerable  fever  aconite  or  belladonna  will  be  service- 
able ;  and  in  case  of  orchitis,  the  recumbent  posture  must  be 
observed.  Mercurius  should  be  given  if  the  glands  show  any 
tendency  to  permanent  enlargement,  or  auruin  muriaticum. 

The  patient  should  remain  indoors  until  all  swelling  has  sub- 
sided, and  if  the  testicle  has  been  involved  he  should  wear  a 
suspensory  bandage 'for  some  weeks  after  apparent  recovery. 


PART    VI  I. 

AFFECTIONS   OF   THE   HEART. 


CHAPTER    I. 

POSITION,  ANATOMY,  AND   FETAL  CIRCULATION. 

Position. — The  heart  in  a  child  occupies  a  position  somewhat 
higher  in  the  thorax  than  that  of  an  adult.  The  auricles  are 
on  a  line  with  the  second  intercostal  space,  the  right  extending 
beneath  the  sternum  and  almost  to  its  right  border.  The 
right  ventricle  is  beneath  the  sternum  and  to  its  left ;  its  lower 
border  is  on  a  line  with  the  head  of  the  sixth  costal  cartilage. 
The  left  ventricle  lies  between  the  third  and  fourth  intercostal 
spaces,  and  beneath  the  fourth  rib.  The  position  of  the  apex- 
beat  differs  from  that  of  the  adult.  The  apex  is  much  higher 
and  nearer  the  nipple,  and  in  some  cases  the  nipple  pulsates 
synchronously  with  the  apex-beat.  This  higher  position  of  the 
apex-beat  may  be  due  partly  to  the  distention  of  the  stomach, 
and  the  large  size  of  the  liver  at  this  period  of  life.  The  apex- 
beat  descends  in  position  as  the  child  grows  older.  In  children 
of  six  years  it  is  generally  close  to  the  nipple,  while  at  the  age 
of  twelve  it  is  an  inch  or  more  lower.  The  base  of  the  heart  is 
usually  found  posteriorly  at  the  fifth  dorsal  vertebra.  The 
anterior  surface  of  the  heart  is  removed  from  the  chest  wall  by 
the  lungs.  They  cover  almost  all  of  it  except  the  extreme 
point ;  the  tip  of  the  left  ventricle  and  the  lower  part  of  the 
right  ventricle  only  are  accessible  for  physical  diagnosis.  The 
accessible  portion  forms  a  triangle  having  three  points,  namely  : 
(i)  the  apex-beat  just  below  the  nipple  ;  (2)  the  junction  of  the 
sternum  with  the  ziphoid  cartilage  ;  (3)  the  junction  of  the  left 
costal  cartilage  with  the  sternum.  All  the  four  valvular  open- 
ings in  the  heart  of  a  child  lie  in  close  proximity  within  a  space 
half  an  inch  square.  The  mitral  valve  will  usually  be  found  at 
the  left  border  of  the  sternum,  on  a  level  with  the  upper  border 
of  the  third  costal  cartilage.  The  tricuspid  lies  more  under  the 
sternum,  slightly  in  front  and  a  little  lower.  The  valves  of  the 
pulmonary  artery  are  found  opposite  the  lower  margin  of  the 

(383) 


384  THE  DISEASES  OF  CHILDREN. 

second  interspace.  The  aortic  opening  is  slightly  lower  in  an 
oblique  direction.  For  a  definition  and  description  of  the 
normal  sounds  of  the  heart,  the  reader  is  referred  to  the  classi- 
cal text-books. 

The  study  of  a  case  of  suspected  disease  of  the  heart  in  a 
child  is  beset  with  difficulties  not  met  with  in  an  adult. 

Method  of  Study. — If  you  commence  to  examine  immediately 
after  the  child  is  prepared  by  removing  the  clothing,  the  sight 
of  the  instruments  will  stir  up  the  circulation  to  such  an  extent 
that  you  cannot  make  a  correct  diagnosis.  While  the  child  is 
being  quieted  and  growing  accustomed  to  your  presence,  inquire 
into  the  previous  history.  Has  your  patient  had  scarlatina, 
measles,  rheumatism,  or  any  diseases  with  a  known  tendency 
to  cause  endo-  or  pericarditis  ?  Observe  the  appearance  of 
the  skin,  if  there  is  a  normal  capillary  circulation,  especially 
about  the  face  and  finger-nails  ;  the  expression  of  the  face  ;  the 
presence  of  dropsy  or  anasarca ;  the  condition  of  the  respira- 
tion ;  the  presence  of  cough ;  the  appearance  of  the  alae  nasi 
and  the  color  of  the  mucous  surfaces.  First,  notice  by  inspec- 
tion if  the  apex-beat  is  a  normal  position.  By  palpation  with 
the  tips  of  the  fingers  observe  the  apex-beat.  It  should  be 
limited  in  area,  well  defined  and  punctated.  It  should  give 
evidence  of  a  first  and  second  sound  ;  the  former  by  a  dull, 
long  vibration,  the  latter  by  a  short  and  distinct  impulse 
against  your  finger  tips. 

Percussion  of  the  heart  of  a  child,  unless  it  is  soporose  or 
very  docile,  is  very  difficult,  requiring  great  skill  and  tact.  The 
patient  should  sit  upright  ;  commence  at  the  middle  of  the  left 
clavicle  and  proceed  downward  until  a  dull  sound  tells  you  the 
upper  border  of  the  heart  is  reached.  Then  percuss  from  the 
right  side  of  the  sternum  on  a  level  with  the  fourth  rib,  directly 
across  the  bone,  until  at  about  its  left  edge  you  find  the 
dullness  which  shows  the  heart  is  reached.  In  both  cases,  con- 
tinue across  the  area  of  dullness  until  a  clear  note  is  heard, 
showing  the  lung  is  reached. 

You  will  find,  however,  percussion  so  unsatisfactory  that  you 
will  learn  to  rely  almost  whoU)'  on  auscultation  as  a  means  of 
diagnosis.  The  two  best  stethescopes  are  Soule's,  and  Edwards'. 
The  rubber  vacuum  cup  of  the  former  adheres  and  does  not 
need  to  be  pressed  against  the  skin,  a  process  decidedly  ob- 
jected to  by  children.  Edwards'  bin-aural  is  very  light  and  is 
the  best  of  the  kind. 

Place  the  child  in  an  upright  position.  Apply  the  stethescope 
closely  to  the  bare  skin.  The  auscultator's  head  should  not  be 
too  low,  this  is  very  essential.  You  will  then  detect  two  sounds 
very  different  in   character.     The  so-called  first  sound  is  low. 


THE  HEART— FETAL   CIRCULATION.  385 

dull,  booming  and  seems  close  to  the  ear;  the  second  sound  is 
short,  abrupt,  winging  or  flopping.  These  two  sounds  in  chil- 
dren are  audible  over  the  entire  region  of  the  heart,  and  in  fact 
all  over  the  thorax,  but  the  sounds  are  heard  most  distinctly 
over  the  seat  of  their  production. 

Full  inspiration  lessens  the  sounds  very  materially ;  full  ex- 
pirations increase  the  extent  over  which  they  may  be  heard. 
Note  whether  the  sounds  are  obscure  or  clear,  the  periods  of 
pause,  or  any  change  in  rhythm.  Remember  that  the  normal 
heart  of  a  child  may  beat  irregularly  or  intermittently  ;  but  that 
such  arythma  is  always  suspicious.  If  the  heart  is  not  diseased, 
it  may  be  the  brain  or  liver,  or  may  arise  from  some  intestinal 
disorder. 

The  Fetal  Circulation. — Owing  to  certain  differences  which 
exist  between  the  fetal  and  adult  heart,  the  circulation  of  the 
blood  in  the  fetus  in  utero  differs  from  that  of  the  child  after 
birth.  This  fetal  circulation  should  be  understood  and  studied, 
or  you  will  not  be  able  to  appreciate  congenital  diseases  and 
malformations  of  the  heart. 

"  The  following  is  a  brief,  but  yet  explicit,  resume  of  the 
fetal  circulation :  Blood  is  conveyed  through  the  umbilical 
arteries,  which  are  terminations  or  branches  of  iliac  arteries,  to 
the  placenta,  where,  within  the  villi  of  the  chorion,  the  inter- 
changes with  the  maternal  blood  take  place.  After  being  thus 
renovated  and  recharged  with  oxygen,  it  collects  within  the 
umbilical  vein  from  innumerable  branches,  and  passes  back 
through  the  umbilical  cord  to  the  liver.  The  blood  thus  re- 
turned to  the  fetus  is  arterial,  and  that  which  passed  through 
the  umbilical  arteries,  venous ;  but  it  is  so  in  a  modified  sense 
only.  After  reaching  the  liver,  on  its  return  from  the  placenta, 
a  part  of  it  first  circulates  through  the  liver,  and  then  passes 
out  through  the  hepatic  veins,  while  the  rest  goes  through  the 
ductus  venosus  into  the  inferior  vena  cava,  and  both  of  these 
streams  uniting  in  this  vessel,  continue  on  to  the  right  auricle.  The 
two  columns  of  blood,  that  is,  the  blood  passing  into  the  vena 
cava  from  the  hepatic  vein  and  from  the  ductus,  join  the  stream 
which  has  been  collected  from  the  lower  part  of  the  body,  and 
mix  with  it.  In  early  fetal  life  the  inferior  vena  cava  opens  at 
the  septum  of  the  auricles  into  both  cavities,  though  the  chief 
part  of  the  blood  enters  the  left,  owing  to  the  increased  devel- 
opment of  the  eustachian  valve.  Subsequently  this  valve  becomes 
smaller,  and  by  the  increased  development  of  the  valve  guard- 
ing the  foramen  ovale,  the  current  is  turned  more  and  more 
into  the  right  auricle.  In  this  cavity  the  blood  is  partly  mixed 
with  that  which  enters  from  the  superior  vena  cava,  and  a  part 
of  it  descends  into  the  right  ventricle,  whence  it  passes,  in  part, 
D.  C— 25 


386  THE  DISEASES  OF  CHILDREN. 

through  the  pulmonary  artery  into  the  lung  tissue.  No  proper 
pulmonary  circulation  having  yet  been  established,  only  about 
half  the  blood  contained  in  the  right  ventricle  enters  the  pul- 
monary artery,  while  the  other  half  enters  the  descending  aorta 
through  the  ductus  arteriosus.  The  imperfectly  developed 
pulmonary  veins  convey  to  the  left  auricle  but  a  small  quantity 
of  blood,  the  chief  supply  being  received  from  the  right  auricle 
through  the  foramen  ovale,  through  which  passes  the  main 
stream  from  the  inferior  cava.  From  the  left  auricle  the  blood, 
which  is  semi-arterial,  descends  into  the  left  ventricle,  and 
thence  into  the  first  division  of  the  aorta.  By  virtue  of  this 
movement  the  head  and  upper  extremities  are  supplied, 
through  the  carotid  and  subclavian  arteries,  with  tho  blood 
which  has  been  but  little  deteriorated  in  quality,  and  escapes 
the  more  venous  current  from  the  right  ventricle  through  the 
ductus  arteriosus." — Leavitfs  Obstetrics. 

"The  establishment  of  independent  circulation  takes  place 
as  soon  as  the  child  is  born.  The  first  act  of  the  new-born  babe 
is  a  lusty  cry  which  inflates  the  lungs,  and,  in  consequence, 
dilates  the  pulmonary  arteries.  As  a  sequence,  the  greater  part 
of  the  blood  in  the  right  ventricle  is  at  once  distributed  to  the 
lungs,  where  it  becomes  changed  from  venous  to  arterial  blood, 
and  is  returned  through  the  pulmonary  veins  to  the  left  auricle. 
The  left  auricle  now  receives  more  blood  than  it  has  been 
accustomed  to,  the  right  less,  and,  owing  to  arrest  of  the 
placental  circulation,  the  umbilical  veins  are  inactive.  We  now 
find  that  the  pressure  of  the  blood  in  the  two  auricles  is  equal- 
ized, which  aids  in  the  closure  of  the  foramen  ovale. 

"  The  blood  no  longer  finds  its  way  from  right  to  left  auricle^ 
but  into  the  right  ventricle,  and  thence  to  the  pulmonary 
artery.  The  ductus  arteriosus  becomes  impervious,  and  soon 
collapses.  The  blood  in  the  descending  aorta  does  not  find  its 
way  into  the  hypogastric  arteries,  but  directly  into  the  lower 
extremities,  and  adult  circulation  is  established." — Keating  on 
the  Hearts  of  Children. 


CHAPTER  II. 

CONGENITAL   DISEASES   OF  THE  HEART. 

"After  birth  the  foramen  ovale  soon  becomes  permanently 
closed,  probably  by  contracting  adhesions  to  the  edges  of  the 
aperture.  The  umbilical  arteries  and  veins  and  the  ductus 
venosus  speedily  collapse  and  become  impervious.  Any  one  of 
these  structures  may  remain  pervious  and  constitute  some  of 
the  circulatory  anomalies  due  to  arrested  development  or  want 
of  proper  completion  in  the  stages  of  change  from  fetal  to  adult 
circulation.  The  foramen  ovale  sometimes  remains  open  or 
imperfectly  closed.  Some  observers  state  that  the  valve  is 
never  completely  obliterated  until  the  eighteenth  month  or 
second  year  of  extra-uterine  life.  In  many  cases,  the  patulous 
foramen  is  secondary  to  defects  in  the  mitral  valve,  allowing 
regurgitation  or  obstruction  in  the  large  arterial  trunks,  aorta, 
and  pulmonary  artery.  A  patulous  foramen  is  more  frequently 
associated  with  obstruction  or  narrowing  of  the  pulmonary 
artery.  Narrowing  of  the  tricuspid  orifice  would  also  be  a  di- 
rect cause  of  patulous  foramen  ovale,  but  primary  defects  in 
the  tricuspid  orifice,  causing  narrowing  or  stenosis,  are  very  rare ; 
in  fact,  it  is  rare  that  we  see  it  even  in  combination  with  other 
defects.  It  may  be,  and  generally  is,  due  to  narrowing  of  the 
pulmonary  artery.  As  a  rule,  the  direction  of  the  blood-cur- 
rent, in  cases  of  patulous  foramen  ovale,  is  the  same  as  that 
during  fetal  life,  i.  e.,  from  right  to  left  auricle ;  but  cases  have 
been  noted  in  which  the  direction  of  the  blood-current  was  di- 
rectly opposite  from  that  which  pertains  during  intra-uterine 
life,  i.  e.,  from  left  to  right." — Keating  and  Edwards. 

I  shall  not  mention  other  malformations,  as  they  are  not 
amenable  to  treatment,  and  cannot  be  included  in  a  work  of 
this  scope.  For  a  study  of  those  the  reader  is  referred  to  that 
admirable  treatise  on  "  Diseases  of  the  Heart  in  Children,"  by 
Keating  and  Edwards. 

The  symptoms  of  these  congenital  defects  should  be  studied 
in  order  to  make  a  diagnosis.  Many  children,  at  birth,  present 
an  intensely  blue  discoloration,  which  more  or  less  speedily 
passes  away,  depending  upon  the  voluntary  or  artificial  estab- 

(387) 


388  THE  DISEASES  OF  CHILDREN. 

lishment  of  respiration,  whereby  the  circulatory  organs  are  ren- 
dered active.  If  the  discoloration  continues,  some  congenital 
malformation  of  the  heart  or  great  vessels  should  be  suspected. 
So,  also,  if  a  child,  a  few  weeks  after  birth,  develop  cyanosis ; 
it  is  almost  positive  proof  of  some  congenital  defect.  If  due 
to  that  cause  a  murmur  maybe  heard,  together  with  quickened 
pulse  and  rapid  heart  action.  If  the  defect  is  compatible  with 
life,  the  patient  may  live  several  years,  and  even  pass  through 
youth  to  manhood.  Keating  mentions  the  case  of  a  girl  who 
remained  in  bed  until  sixteen  years  old.  I  have  known  several 
men,  aged  respectively  eighteen,  twenty-four  and  thirty,  whose 
foramen  ovale  never  closed.  They  were  slim  and  poorly  nour- 
ished, and  never  became  capable  of  much  physical  exertion. 
Cyanosis  may  not  always  be  present.  Dyspnea  on  exertion 
is  always  present.  The  temperature  is  often  sub-normal,  espe- 
cially when  the  patient  nears  dissolution.  Cough  is  almost 
always  present.  There  may  be  chronic  bronchitis  with  bloody 
expectoration.  The  subjects  are  prone  to  congestion  of  the 
spleen,  liver  and  kidneys,  and  to  dropsy  with  albuminuria. 
The  fingers  may  be  clubbed,  nails  bent,  or  ulcerated  around 
the  margin. 

Treatment. — We  can  do  but  little  in  the  treatment  of  con- 
genital defects.  The  main  aim  is  to  keep  up  the  integrity  of 
the  cavities  of  the  heart,  just  as  we  should  in  cases  of  threat- 
ened hypertrophy  with  dilatation  in  adult  life.  The  chief 
medicines  are  cactus,  digitalis,  nux  vomica,  and  phosphate  of 
lime.  Rest,  both  of  body  and  mind,  is  imperative,  when  we 
fear  imperfect  compensation.  The  child  should  be  fed  (if  not 
nursing)  on  good,  nutritious,  muscle-making  food.  The  posi- 
tion, when  lying,  should  be  on  the  back  or  right  side.  A  warm, 
dry  or  moist  climate  is  preferable.  I  sent  two  patients  to 
South  Florida,  who  lived  there  comfortably  when  they  could 
not  live  so  in  the  North. 


CYANOSIS. 

This  is  sometimes  called  the  "blue  disease."  It  is  one  of 
the  most  constant  and  prominent  symptoms  of  congenital 
heart  disease.  It  may,  however,  be  acquired,  and  be  caused 
by  endo  or  pericardial  inflammation ;  it  may  be  present  in 
hydropericardium,  or  any  active  pericardial  effusion.  Dr.  Wa- 
ters {Phil.  Med.  Examiner,  1850)  relates  a  case  in  which  cyano- 
sis developed  in  a  child  aged  six  during  an  attack  of  measles, 
and  remained  persistent.  Another  case  is  reported  in  which  a 
six-months  babe  received  a  severe  fall,  and  was  cyanotic  always 


THE  HEART— CYANOSIS.  389 

afterwards.  Many  other  such  cases  are  on  record.  Cyanosis 
may  be  caused  by  a  stasis  in  the  venous  current  independently 
to  a  certain  extent  of  the  admixture  of  venous  and  arterial 
blood,  but  if  the  latter  occurs  the  color  will  be  a  great  deal 
darker.  It  is  a  strange  fact,  however,  that  there  may  be  a 
complete  mixture  of  the  blood  without  any  cyanosis  whatever. 
Any  cause  which  prevents  a  return  of  venous  blood  to  the 
heart,  or  its  proper  oxygenization  in  the  lungs,  will  cause 
cyanosis.  All  the  cardiac  poisons  which  paralyze  the  heart 
will  cause  a  degree  of  cyanosis.  J.  Lewis  Smith  ("  Diseases 
of  Children  ")  says  cyanosis  is  more  common  in  male  than  in 
female  children.  He  also  says  that  large  cities  return  the 
largest  proportion  of  cyanotic  cases.  It  is  found  principally 
among  the  lower  classes,  who  have  a  perpetual  struggle  for 
existence,  living  in  low,  damp,  ill-ventilated  rooms,  with  scanty 
food  and  clothing,  and  with  wretched  hygienic  surroundings. 
Such  conditions  inevitably  result  in  imperfect,  or  arrested 
development  of  children,  even  in  the  uterus. 

Cyanosis  due  to  congenital  defects  may  not  appear  at  birth. 
Smith  gives  41  cases ;  in  3  it  appeared  in  two  weeks,  i  at  three 
weeks,  2  at  one  month,  7  from  one  to  two  months,  5  from  six 
to  twelve  months,  3  from  one  to  two  years,  i  from  five  to  ten 
years,  6  from  ten  to  twenty  years,  i  from  twenty  to  forty  years, 
and  I  over  forty  years.  This  shows  that  a  congenitally  crip- 
pled  heart  may,  in  some  cases,  carry  on  life  many  years,  con- 
forming itself  to  a  disordered  blood  circulation,  and  continue 
to  grow  in  strength  until  some  accident  or  disease  "  breaks  the 
compensation." 

Treatment. — After  cyanosis  once  appears  and  is  due  to  a 
structural  cardiac  defect,  a  cure  is  very  rare,  but  considerable 
improvement  may  occur.  Rest,  good  nourishment,  avoidance 
of  all  excitement,  bodily  or  mental,  with  a  warm  climate  or 
warm  clothing,  must  be  insisted  on.  The  medicines  which 
cause  venous  stasis  with  imperfect  oxygenization  of  blood — or, 
to  be  more  exact,  which  cause  cyanosis  primarily — as  lauro- 
cerasus,  hydrocyanic  acid,  cyanuret  of  potash,  etc.,  are  not  in- 
dicated in  this  disease.  Only  those  are  useful  which,  by  their 
action  on  the  muscular  fibers  of  the  heart,  tend  to  prevent 
dilatation  of  its  cavities.  The  most  prominent  of  them  are 
digitalis,  cactus,  strophanthus,  anhalonium,  spigelia,  spongia, 
convallaria,  coffea,  etc.,  given  in  doses  suitable  to  the  age  of 
the  child.  If  the  blood  is  actually  impoverished,  ferrum  and 
manganese,  with  ignatia  and  nux  vomica,  should  be  given,  and 
those  meats  which  are  rich  in  blood-making  material.  Con- 
stipation or  hepatic  torpor  must  not  be  allowed  to  exist,  as 
improvement  will  be  greatly  retarded  thereby. 


390  THE  DISEASES  OF  CHILDREN. 

VALVULAR     DISEASES. 

Valvular  lesions  in  children  are  usually  caused  by  rheumatic 
endocarditis.  More  rarely  are  they  caused  by,  or  occur  during 
the  progress  of,  Bright's  disease.  As  before  stated,  they  may 
be  congenital.  They  occur  during  chorea,  and  it  is  still  a  dis- 
puted question  whether  chorea  is  altogether  of  rheumatic  origin 
or  often  caused  by  a  specific  bacilli.  If  the  latter,  we  need  not 
be  surprised  to  find  that  they  invade  the  valves  of  the  heart. 

The  diagnosis  of  valvular  disease  of  the  heart  in  children  is 
governed  by  the  same  rules  as  for  the  adult,  with  the  exception 
that  the  position  of  the  heart  in  health  and  disease  is  higher  in 
the  thorax  in  children.  This  I  have  mentioned  on  previous 
pages.  In  vol.  2  of  "  The  London  Homeopathic  Hospital  Re- 
ports," 1892,  is  an  excellent  paper  by  Dr.  E.  A.  Neatby,  assistant 
physician,  containing  "original  investigations  respecting  the  posi- 
tion of  the  heart's  apex-beat  in  children."  The  following  summary 
of  the  conclusions  were  based  on  two  hundred  measurements  in 
cases  where  no  deformity  of  the  chest  was  present,  and  no  dis- 
ease of  the  heart  or  lungs.     The  age  limit  was  fourteen  years. 

"  I.  That  the  heart's  apex-beat  is  sitireited  more  externally  in 
children  than  in  adults. 

2.  That  it  is  quite  exceptional,  if  not  abnormal,  for  it  to  be 
found  external  to  the  nipple  line. 

3.  That  the  relative  distance  of  the  apex-beat  from  the 
nipple  line  varies  rather  with  the  age  of  the  subject  than  with 
the  size  of  the  thorax. 

4.  That  the  more  external  position  in  children  is  explained 
by  the  large  size  of  the  heart  and  by  the  small  transverse  meas- 
urement of  the  chest  in  these  subjects. 

5.  That  the  size  and  state  of  distention  of  the  abdominal 
organs  furnish  a  less  constant  cause  for  variation  of  the  position 
of  the  heart. 

6.  That  the  heart  is  situated  also  at  a  higher  level  in  the 
thorax  than  in  adults,  and  that  this  is  especially  the  case  in 
infants. 

7.  That  the  apex-beat  is  felt  at  a  higher  level  in  the  recum- 
bent than  in  the  erect  posture. 

8.  That  the  heart's  sounds  are  more  widely  audible  in  the 
chest  of  the  child  than  of  the  adult. 

The  most  direct  method  of  diagnosis  of  valvular  disease  is 
by  auscultation. 

Most  valvular  murmurs  are  due  to  a  change  at  the  valvular 
orifice  ;  either  a  narrowing  or  stenosis,  or  an  insufficiency  with 
an  inability  to  close  the  aperture,  permitting  regurgitation. 
The   possible   valvular   murmurs   in    the   heart   (exclusive   of 


THE  HE  A  RT— VALVULAR  DISEA  SES.  391 

congenital  effects)  are  caused  by  obstruction  or  regurgitation  of 
mitral,  tricuspid,  aortic  and  pulmonary  valves.  Thus  we  may 
have  two  murmurs  to  each  valve,  or  eight  in  all.  Some  of  them 
are  so  rare  that  the  general  practitioner  is  likely  to  overlook 
them.  If  the  heart-beats  are  very  rapid,  we  may  not  be  able 
to  hear  the  murmurs  as  distinct  sounds.  They  have  all  a  com- 
mon quality,  they  are  all  blowing ;  yet  the  sound  itself  may 
present  all  variations  in  the  musical  scale.  The  various  names 
given  to  these  sounds  as  sawing,  cooing,  etc.,  have  but  little 
practical  value,  as  they  teach  us  nothing  as  to  the  real  source 
of  the  sound. 

These  murmurs  are  not  always  heard  with  equal  distinct- 
ness ;  change  of  position  may  cause  them  to  disappear  or  to 
become  very  faint.  Exercise  or  undue  .pressure  of  the  stothe- 
scope  will  cause  abnormal  sounds  to  become  louder.  A  murmur 
may  be  absent  when  the  child  is  in  absolute  rest.  It  is  very 
difficult  to  decide  whether  the  murmur  occurs  during  the 
systole  or  diastole.  It  is  asserted  that  a  sound  which  occurs 
synchronously  with  the  apex-beat  is  systolic,  no  matter  what 
its  characteristics  are. 

Having  discovered  the  existence  of  a  murmur  in  the  heart 
we  must  next  definitely  locate  its  seat  and  character — whether 
it  is  an  obstruction  or  a  regurgitation.  The  fact  that  a  sound 
has  its  maximum  intensity  near  the  seat  of  production,  the 
closer  we  approach  this  seat  the  louder  will  the  murmur  become. 
The  cut  (page  392)  from  DaCosta  shows  us  where  the  various 
valves  are  located,  and  it  will  aid  in  identifying  the  locality  of 
the  murmur. 

The  scope  of  this  work  will  not  permit  complete  directions 
for  auscultation  in  the  various  valvular  diseases  of  the  heart. 
Reference  must  be  had  to  special  works  on  diseases  of  the 
heart.  (Keating  &  Edwards  ;  Hale  ;  Clapp  on  "Auscultation 
and  Percussion.") 

"After  we  have  found  a  mitral  stenosis,  or  insufficiency,  our 
diagnosis  is  not  complete  until  we  have  recognized  the  general 
and  local  changes  consequent  on  their  presence.  In  both,  the 
chambers  of  the  heart  speedily  become  deranged,  some  by  dila- 
tation, and  others  by  hypertrophy,  or  by  a  combination  of  both. 
The  left  ventricle  is  usually  found  in  a  condition  of  hyper- 
trophy, as  it  receives  the  blood  under  high  pressure  from  the 
pulmonary  veins,  and  furthermore,  it  performs  all  its  functions 
under  high  pressure  also.  The  left  auricle  is  always  dilated, 
and  the  right  ventricle  hypertrophied.  The  early  alteration  in 
the  heart  cavities  is  not  manifested  by  any  disagreeable  symp- 
toms in  the  patient  until  the  compensation  is  deranged,  and 
the  cardiac  equilibrium  is  interfered  with.     Then  symptoms 


392 


THE  DISEASES  OF  CHILDREN. 


such  as  palpitation,  cougn,  snortness  of  breath,  and  dropsy 
appear. 

"  Tricuspid  Disease. — Primary  disease  of  the  tricuspid  valve 
is  very  unusual,  except  those  cases  of  pre-natal  origin.  It  less 
rarely  occurs  secondarily  dependent  on  mitral  disease  which  has 
weakened  the  right  heart. 


Sortie  vO'lves- 


hclmoTvary  arter'y  vaUifif 


Cral 


Diagram  showing  the  points  at  which  the  separate  valves  may  be  listened  to. 


"Stenosis  is  more  rare  than  incompetency — so  rare  that  it  is 
hardly  worth  while  to  consider  it. 

"  Insufficiency  causes  many  serious  symptoms  ;  the  first  effect 
is  to  cause  the  right  auricle  to  become  dilated  and  hypertro- 
phied  ;  then  the  right  ventricle,  which  soon  encroaches  upon  the 
left  heart.     The  portal  system  becomes  congested,  the  liver 


THE  HE  A  RT— VALVULAR  DISEA  SES.  398 

enlarged,  and  hemorrhoids  may  arise.  The  urine  becomes 
scanty  and  even  suppressed.  Edema  and  anasarca  arise  rather 
later  than  in  other  valvular  diseases. 

^^  Aortic  insufficiency,  arising  primarily  in  infants,  is  among 
the  uncommon  clinical  observations,  excluding  cases  having 
congenital  origin  ;  in  older  children  it  is  not  at  all  rare.  The 
etiology  of  aortic  insufficiency  is  much  the  same  as  we  have  al- 
ready considered  in  treating  of  the  general  subject  of  valvular 
disease.  At  this  valve,  however,  we  are  more  likely  to  have 
an  insufficiency  suddenly  produced  during  sudden  exertion  from 
the  rupture  of  a  segment  of  the  valve,  occurring  usually  at  the 
free  border  ;  sometimes,  however,  at  the  insertion  of  a  leaflet. 
It  is  difficult  to  believe  that  a  healthy  valve  would  rupture  un- 
der these  circumstances,  and  we  must  admit  the  existence  of  a 
previous  valvular  disease,  which  has  weakened  its  structure. 

^^ Symptoms  and  Physical  Signs. — Of  all  the  cardiac  diseases, 
this  is  certainly  the  most  easily  recognized,  both  on  account  of 
its  characteristic  general  symptoms  and  the  acuteness  with 
which  the  physical  signs  are  defined.  Corrigan  first  recognized 
this  fact  by  describing  the  'visible  pulse,'  so  marked  in  this 
disease.  The  pulse  is  sudden  and  bounding,  giving  an  impres- 
sion of  seeming  strength ;  but  it  is  elevated  suddenly,  and  falls 
immediately.  In  the  words  of  Corrigan,  'The  arterial  trunks 
of  the  head,  neck,  and  upper  limbs  at  once  attract  the  eye  by 
their  peculiar  pulsations ;  at  each  diastole  the  subclavian,  car- 
otid, temporal,  humeral,  and  sometimes  even  the  palmar  arteries 
are  projected  forcibly  from  their  bed  and  bound  under  the  skin.' 
In  order  to  better  observe  these  points,  we  are  in  the  habit  of 
having  the  patient  strip  one  arm,  and  preferably  one  side  of  the 
chest,  separating  the  arm  from  the  body,  semi-flexing  and  supi- 
nating  the  forearm ;  the  observer,  at  a  glance,  will  be  able  to 
note  the  entire  course  of  the  arteries  under  consideration.  Cor- 
rigan's  original  explanation,  which  has  stood  the  test  of  years, 
cannot  be  improved  upon:  'When  the  semi-lunar  valves  are 
healthy,  they  are  closed  by  the  pressure  of  blood  immediately 
after  each  ventricular  contraction.  When  the  occlusion  is  com- 
plete, the  blood  propelled  from  the  ventricle  is  retained  in  the 
aorta,  and  the  large  vessels  remain  distended.  These  vessels 
then  maintain  almost  the  same  caliber  in  systole  as  in  diastole. 
But  when  the  valves  no  longer  close  the  aortic  orifice,  a  certain 
amount  of  blood  contained  in  them  is  allowed  to  escape;  they 
become  flaccid  after  each  ventricular  contraction,  and  their 
diameter  diminishes.  At  this  moment  a  fresh  contraction  of 
the  ventricle  rapidly  forces  into  the  vessels  a  quantity  of  blood, 
which  dilates  them  forcibly  and  suddenly.  The  arterial  dias- 
tole is  then  marked  by  such  a  sudden  increase  in  the  caliber  of 


394  THE  DISEASES  OF  CHILDREN. 

the  vessel  that  it  produces  a  visible  pulsation,  constituting  one 
of  the  signs  of  the  disease.'  The  murmur  is  heard  at  the  sec- 
ond right  costal  cartilage,  '  the  aortic  cartilage  ; '  it  is  heard  as 
high  as  the  upper  border  of  the  second  intercostal  space,  also 
slightly  to  the  right  of  the  sternum,  and  descending  downwards 
throughout  the  extent  of  the  bone,  inclining  a  little  to  the  left 
as  the  ensiform  cartilage  is  approached.  Aortic  insufficiency 
is  accompanied  by  a  murmur,  which  is  diastolic  in  time,  replac- 
ing the  click  of  the  semi-lunar  valves  and  commencing  with 
cardiac  diastole,  consequently  occupying  the  greater  portion  of 
the  period  of  silence ;  it  terminates  with  the  diastole,  or  bet- 
ter— the  murmur  is  cut  short  by  the  next  systole.  The  sys- 
tole will  be  found  to  be  shorter  than  normal,  with  a  rapid 
subsidence.  As  the  heart  becomes  hypertrophied,  the  mur- 
mur becomes  more  distinct  and  presents  greater  areas  of  trans- 
mission. 

"The  general  symptoms  in  young  patients  are  apt  to  be 
latent  for  a  long  time,  and  the  sole  manifestations  are  the  physi- 
cal signs.  Later,  hypertrophy  of  the  left  ventricle  arises  and 
the  apex  becomes  lower  than  normal,  producing  an  epigastric 
impulse,  and  displacing  the  left  lobe  of  the  liver  downwards. 
As  the  case  advances,  the  cardiac  chambers  become  dilated ;  it 
is  then  that  we  note  an  increase  in  the  vertical  diameter  of  the 
heart ;  the  tricuspid  may  become  insufficient  by  a  process  of 
simple  dilatation  of  the  orifice. 

"The  patient,  if  perfectly  quiet,  will  be  in  comparative  com- 
fort, but  the  slightest  exertion  will  produce  palpitation  and 
distress,  with  a  feeling  of  anxiety  and  oppression.  Dyspnea 
becomes  an  exacting  symptom,  which  muscular  exercise  or 
mental  worry  will  increase  to  apnea  ;  it  is  the  duty  of  the  physi- 
cian in  these  cases  to  warn  the  parents  or  guardian  of  the  neces- 
sity of  correcting  the  child  in  a  mild  manner,  and  to  especially 
caution  them  against  the  danger  of  violent  whipping  or  seclud- 
ing the  child  in  a  lonely  or  dark  room.  Parents  should  see 
that  these  children  are  not  unduly  excited  by  their  nurses 
reciting  '  ghost  stories,'  or  tales  of  reckless  daring,  culled  from 
the  unfortunately  prevalent  poor  literature  of  the  day.  Among 
the  most  alarming  cases  that  we  have  been  called  upon  to  treat 
have  been  examples  of  'night  horror'  in  young  children  with 
valvular  diseases,  whom  a  nurse  or  elder  brother  or  sister  has 
conned  to  sleep  by  some  story  gleaned  from  the  cheap  weekly 
papers  scattered  so  broadcast  throughout  the  country. 

"  Occasional  attacks  of  angina  pectoris  may  arise,  alarming 
the  patient  greatly,  and  introducing  a  new  and  serious  element 
in  the  prognosis.  The  natural  course  of  the  disease  in  the 
young  is  slow  ;  when  dilated  hypertrophy  arises,  we  then  note 


THE  HE  A  R  T—  VALVULAR  VISE  A  SES.  395 

the  symptoms  of  venous  tension,  congestion  of  the  portal  and 
pulmonary  veins,  with  edema  of  the  extremities."* 

Treatment. — The  treatment  of  valvular  disease  of  the  heart, 
especially  in  children,  is  not  altogether  medicinal.  Without 
proper  hygienic  measures,  drugs  can  do  but  little  to  assist  the 
heart  to  overcome  the  lesions  of  its  valves.  Aided  by  a  regu- 
lated life  of  the  patient,  the  vis  medicatrix  natures  must  do  all 
the  rest.  The  cure,  or  a  condition  approaching  it,  is  brought 
about  by  a  process  which  is  called  compensation.  It  would  be 
in  vain  for  me  to  attempt  to  describe  this  process  in  my  own 
words  as  clearly  as  it  is  described  by  Bramwell  in  his  great  work 
on  the  "  Heart  and  its  Diseases,"  and  I  shall  therefore  take  the 
liberty  of  quoting  from  that  author.     He  says  : 

"  It  might  be  supposed  that  every  structural  alteration  which 
produces  either  stenosis  or  incompetence  of  a  valvular  orifice, 
is  necessarily  attended  by  symptoms  due  to  disturbance  of  the 
circulation  ;  and  such,  in  truth,  would  be  the  case,  if  it  were 
not  for  the  fact,  that  nature  adapts  herself  to  the  altered  con- 
dition of  things ;  and  that  certain  secondary  changes  are  grad- 
ually established,  by  virtue  of  which  the  bad  effects  of  derange- 
ment of  the  circulation  are  resisted,  and  by  means  of  which  the 
normal  balance,  so  to  speak,  of  the  circulation  is  maintained 
or  reestablished.  There  is,  in  short,  in  almost  all  cases  of 
valvular  defect,  a  natural  effort  to  compensate  the  lesion,  the 
importance  of  which,  in  a  practical  point  of  view,  it  is  impossible 
to  overestimate. 

"  The  compensatory  changes  consist  of  alterations  in  the 
heart,  the  object  of  which  is  to  restore  and  maintain  the  balance 
of  the  circulation,  and  to  resist  the  injurious  effects  of  the  le- 
sions on  the  heart  itself,  and  of  certain  changes  in  the  peripheral 
tissues,  by  means  of  which  the  injurious  effects  of  backward 
pressure  and  venous  stagnation  are,  to  some  extent,  prevented." 

The  exact  nature  of  these  compensatory  changes,  which  de- 
pend upon  (i)  the  valve  which  is  affected,  and  (2)  the  manner 
in  which  it  is  affected  {i.  c.,  whether  stenosis  or  incompetence  is 
the  chief  lesion),  will  be  more  appropriately  considered  when  I 
come  to  treat  of  the  individual  valvular  lesions  in  detail  ;  but, 
speaking  broadly,  I  may  say  that  in  all  lesions  compensation  is 
chiefly  effected  by  hypertrophy  of  the  walls  of  the  cardiac  cav- 
ity or  cavities,  which  are  situated  behind  the  affected  orifice. 
Alterations  in  the  frequency  of  the  cardiac  contractions  also 
exert  an  important  compensatory  influence,  more  especially,  as 
we  shall  afterwards  see,  in  the  case  of  aortic  lesions.  When,  for 
instance,  the  aortic  orifice  is  contracted,  the  muscular  wall  of 


*  Keating  and  Edwards. 


396  THE  DISEASES  OF  CHILDREN. 

the  left  ventricle  becomes  thicker,  and  the  "  driving  "  power  of 
the  left  heart  being  materially  increased,  a  larger  quantity  of 
blood  is  propelled  in  a  given  time  through  the  narrowed  orifice 
than  could  possibly  have  been  the  case  in  the  normal  (unhyper- 
trophied)  condition.  So  again,  stenosis  of  the  mitral  valve  is 
followed  by  hypertrophy  of  the  left  auricle,  but  in  this  case  the 
normal  function  of  the  auricle  being  passive  rather  than  active, 
and  the  resisting  power  of  its  walls  against  the  blood  pressure 
depending  not  only  upon  muscular  tissue,  but  also  upon  the 
connective  tissue  layers  of  the  endocardium,  the  hypertrophy 
consists  not  only  of  an  increase  of  the  muscular  wall  of  the  au- 
ricle, but  also  of  thickening  of  its  elastic  tissue  lining.  By  these 
means  its  resisting  power  is  materially  strengthened,  at  the 
same  time  as  its  propelling  power  is  increased.  The  reader 
must  not  suppose  from  this  statement  that  all  fibroid  changes 
in  the  cardiac  walls  add  to  the  resisting  power  of  the  organ. 
When  the  muscular  tissue  of  the  organ  is  replaced  by  fibrous 
tissue,  as  it  is  in  fibroid  degeneration,  both  the  "  driving  "  and 
resisting  power  of  the  organ  are  diminished.  It  is  only  when 
the  muscular  wall  remains  healthy,  or  is  hypertrophied,  that  an 
increase  of  the  fibrous  tissue  in  the  endocardium  can  possibly  add 
to  its  resisting  power.  This  increase  of  the  connective  tissue 
coat  of  the  auricle  is  (in  proportion  to  the  amount  of  muscular 
hypertrophy)  still  more  marked  in  mitral  incompetence,  in 
which  condition,  as  we  have  previously  seen,  increased  resist- 
ance is  necessary  to  counteract  the  dilating  force  of  the  regur- 
gitant current,  but  in  which  there  is  no  obstruction  to  the  pas- 
sage of  the  blood  from  the  auricle  to  the  ventricle.  So,  again, 
in  aortic  regurgitation,  the  forcible  passage  of  an  abnormally 
large  quantity  of  blood  into  the  cavity  of  the  left  ventricle  dur- 
ing its  diastole  (from  the  aorta  through  the  incompetent  valve, 
and  from  the  left  auricle  through  the  mitral  orifice),  produces 
over-stimulation  of  the  muscular  fiber,  in  consequence  of  which 
hypertrophy  of  the  left  ventricle  is  produced,  as  we  have  al- 
ready seen,  by  the  too  forcible  distension  of  the  cavity  while 
its  walls  are  flaccid  and  relaxed. 

The  hypertrophy,  then,  which  follows  and  accompanies 
valvular  lesions,  is  eminently  beneficial,  though  it  is  not  in  all 
cases  an  unmixed  good ;  and  I  cannot  insist  too  strongly  upon 
the  immense  importance  of  this  doctrine  of  compensation. 
The  symptoms,  as  we  shall  afterwards  see,  are  trivial,  or  alto- 
gether absent,  so  long  as  the  compensatory  changes  are  suffi- 
cient to  balance  the  bad  effects  of  the  lesion  ;  the  prognosis  is 
ver}7  largely  based  upon  the  amount  of  compensation  and  capa- 
bilities of  repair  which  are  present,  while  the  treatment  is  in 
great  part  directed  to  promoting  and  maintaining  the  hypertro- 


THE  HE  A  R  T—  VA'L  VULA  R  DISEA  SES.  397 

phy  and  other  secondary  changes,  by  means  of  which  the 
balance  of  the  circulation  is  restored  and  maintained  in  a  com- 
paratively normal  condition. 

The  amount  of  compensation  which  is  possible  in  any  given 
case,  depends  chiefly  upon  the  following  circumstances : 

I .    The  suddcnfiess,  extent  and  character  of  the  lesion. 

"A  very  extensive  lesion,  which  occurs  suddenly — rupture  of 
the  heart,  for  instance — may,  of  course,  destroy  life  so  rapidly 
that  compensatory  changes  cannot  possibly  occur. 

"  Then,  again,  a  severe  (but  not  immediately  fatal)  lesion, 
which  occurs  suddenly,  is  with  difficulty  compensated.  Ruptures 
and  ulcerations  of  valves  are  examples. 

"  In  other  cases,  on  the  contrary,  in  which  the  progress  of 
the  lesion  is  slow  and  gradual,  compensation  is  easily  estab- 
lished, and  is  very  complete.  In  many  chronic  valvular  lesions, 
for  example,  compensatory  changes  advance  pari  passu  with 
the  morbid  process,  and  for  a  time,  at  least,  the  balance  of  the 
circulation  is  so  satisfactorily  maintained,  that  the  patient 
(provided  that  he  lives  a  quiet  and  tranquil  life,  and  does  not 
suddenly  add  to  the  dif^culties  of  the  circulation)  may  be 
unaware  of  the  existence  of  any  cardiac  defect. 

"2.  TJie  reparative  powers  of  the  patient,  and  especially  the 
capabilities  of  compensation  existing  in  the  heart  itself. 

"  3.  The  resisting  power  of  the  tissues,  which  in  its  turn  de- 
pends upon  the  soundness  and  vitality  of  the  individual  organs, 
and  especially  upon  the  vaso-motor  nerve  tone,  and  the  vitality 
of  the  whole  organism. 

"  In  young  persons,  where  the  tissues  are  healthy,  and  in 
persons  of  good  nerve  tone  and  tranquil  disposition,  compensa- 
tion is  satisfactorily,  and,  for  a  time,  at  least,  efTectually  estab- 
lished. Vice  versa,  in  old  people  and  in  persons  whose  tissues 
are  unsound  or  degenerating,  more  especially  in  those  in  whom 
the  nerve  tone  is  bad,  compensation  is,  from  the  first,  imper- 
fect, and  the  injurious  effects  of  the  lesion  are  speedily  mani- 
fested in  the  form  of  symptoms. 

"  The  condition  of  the  tissues,  then,  as  a  whole,  and  the 
reparative  power  and  vitality  of  the  patient  are  facts  which  the 
practical  physician  must  ever  keep  prominently  in  view.  Indeed, 
we  lay  it  down  as  an  axiom,  that  in  looking  at  cardiac  cases, 
whether  from  a  pathological  or  a  clinical  point  of  view,  and 
more  especially  in  considering  the  prognosis  and  treatment,  it 
is  quite  as  important  (I  might  even  say  that  in  some  it  is  more 
important)  to  look  at  the  condition  of  the  system  as  a  whole, 
as  it  is  to  regard  the  condition  of  the  heart  in  particular.  He 
is,  in  fact,  a  poor  physician  who  concentrates  his  attention  upon 
the  tissue  or  organ  which  is  primarily  affected  ;  and  this  state- 


398  THE  DISEASES  OF  CHILDREN. 

ment  holds  good,  even  should  he  succeed  in  arriving  at  an  ac- 
curate estimate  of  the  cardiac  or  other  local  lesion  ;  while  the 
best  physician  is  he  who  accurately  gauges  the  nature  and 
extent  of  the  local  lesion,  and  at  the  same  time  takes  a  broad 
and  comprehensive  all-around  view  of  the  case." 

I  cordially  subscribe  to  the  excellent  advice  given  by  Bram- 
well  in  his  closing  paragraph.  If  we  have  a  patient — a  child  or 
an  infant — in  whom  we  have  discovered  a  valvular  defect,  the 
first  advice  to  give  to  the  parents  or  nurse,  is  to  see  that  the 
child  is  kept  in  a  condition  of  mental  and  bodily  quiet  until 
compensation  has  fairly  set  in  and  the  muscular  tissue  of  the 
heart  has  gathered  strength  to  overcome  the  resistance  to  which 
it  is  subjected. 

I  do  not  mean  that  ordinary  exercise,  in  well-ventilated 
rooms  or  in  the  open  air,  should  be  forbidden,  but  that  no  un- 
usual exertion  should  be  allowed.  With  children  this  rule  is 
very  hard  to  carry  out,  for  it  is  difficult  to  restrain  their  exuber- 
ant animal  spirits.  It  requires  that  the  watchful  eye  of  an 
attendant  should  always  be  upon  them. 

The  diet  should  be  plain  and  nourishing;  sweet-meats  and 
high  seasoned  dishes  must  be  withheld,  for  it  is  very  necessary 
that  the  stomach  and  intestines  should  be  kept  in  a  healthy 
condition,  in  order  that  food  should  be  properly  digested  and 
assimilated.  I  do  not  believe  that  a  child  with  valvular  disease 
of  the  heart  should  be  allowed  to  go  to  a  public  school.  If 
sent  to  a  private  school,  its  studies  should  be  carefully  selected, 
for  any  cramming  or  overstudy  will  bring  disaster. 

In  some  respects  the  kindergarten  is  objectionable,  because 
the  physical  exercises  in  such  schools  are  often  severe  and  ex- 
citing. Dancing  should  be  absolutely  prohibited  until  some 
competent  physician  decides  that  compensation  has  so  far 
advanced  that  it  is  permissible.  Music  or  other  exciting  amuse- 
ments act  upon  the  heart  injuriously.  Mental  or  emotional  ex- 
citement is  as  bad  for  a  weak  heart  as  gymnastics  or  undue 
physical  exertion. 

Compensation  cannot  take  place  without  good  blood  to  feed 
the  tissues  of  the  heart ;  the  blood  must  be  enriched  by  tissue- 
making  food,  and  if  there  is  any  anemia,  ferrum,  arsenic,  china, 
calcarea,  nux  vomica  and  phosphoric  acid  should  be  given.  A 
residence  in  pure  air  and  the  use  of  mild  ferruginous  waters,  are 
of  the  greatest  value. 

It  is  possible  that  we  may  assist  in  the  resolution  of  swollen 
valves  by  the  use  of  the  iodides  of  lime,  arsenic,  baryta,  aurum, 
or  iron.  Of  these  the  iodide  of  arsenic  is  the  most  valuable. 
I  do  not  advise  stimulating  the  heart  muscle,  but  we  can  aid  com- 
pensation by  giving  the  cardiac  tonics  in  restorative  doses.    We 


THE  HEART— VALVULAR  DISEASES.  399 

should  administer  just  enough  to  aid  nature  in  her  efforts,  care- 
fully avoiding  pathogenetic  effects.  Small  doses  of  digitalis, 
cactus,  strophanthus,  adonis,  convallaria,  coronilla,  spartein, 
caffein,  nux  vomica,  ignatia,  etc.,  can  be  given  a  long  time 
without  causing  any  but  good  results.  We  can  judge  of  their 
good  effects  by  the  character  of  the  pulse  and  the  action  of  the 
heart.  We  should  change  the  remedy  from  time  to  time,  as  its 
effects  seem  to  wear  off.  When  improvement  seems  at  a  stand- 
still under  one  medicine,  another  will  take  up  the  work,  and 
improvement  will  begin  anew. 

While  the  patient  is  under  the  influence  of  physiological 
cardiac  tonics,  all  influences  which  tend  to  weaken  the  heart, 
or  throw  more  work  upon  it  than  it  should  bear,  must  be 
avoided.  Excesses  in  eating  and  drinking  are  injurious,  for 
when  the  stomach  is  overloaded,  the  heart  is  also  overloaded 
with  blood.  This,  with  the  pressure  of  a  distended  stomach 
and  abdomen,  fearfully  taxes  the  strength  of  a  weak  heart  and 
prevents  compensation.  The  same  occurs  when  the  skin  is  not 
in  good  condition.  It  should  be  kept  warm  by  flannel  under- 
wear day  and  night,  for  if  the  skin  is  cold  the  capillaries  are 
contracted  and  an  undue  quantity  of  blood  is  backed  up  against 
the  heart.  I  must  protest  imperatively  against  the  practice  of 
frequent  cold  baths  in  children  with  heart  disease.  A  rapid 
hot  sponge  bath  is  all  that  should  be  given.  Tea  should  not 
be  allowed  children  with  valvular  disease.  Coffee  in  modera- 
tion is  much  less  injurious.  Tobacco  should  not  be  allowed. 
Boys  affected  with  any  form  of  heart  trouble  should  never 
smoke  cigarettes.  The  patients  with  aortic  incompetency 
while  asleep  should  lie  flat  in  bed  on  the  back,  for  in  that 
position  they  lower  the  height  of  the  distending  column  of 
blood,  and  thus  relieve  both  the  cardiac  circulation  and  the 
tendency  to  pulmonary  congestion.  A  change  of  climate  is 
often  necessary  to  favor  compensation.  High  altitudes  are 
injurious  ;  never  send  such  patients  to  Colorado  or  California. 
Low  altitudes  where  the  temperature  is  equitable  and  warm, 
dry  or  moist,  are  best.  Such  resorts  are  found  in  South 
Carolina,  Georgia,  Florida  (particularly  South  Florida  in  win- 
ter), and  some  of  the  Gulf  states.  (See  article  on  the  "  Geogra- 
phy of  Heart  Disease  "  in  Hale's  "  Practice  of  Medicine.") 

The  treatment  of  dropsy  due  to  valvular  disease  must  be 
met  by  cardiac  tonics,  selected  not  from  the  symptoms  alone, 
but  by  the  pathological  condition  of  the  heart  and  kidneys. 
Dropsy  may  be  caused  by  lack  of  arterial  tension  in  the  renal 
circulation,  in  which  case  digitalis  is  the  chief  remedy ;  next  in 
value  are  caffein,  strophanthus,  adonis,  convallaria,  salicylate 
of    theobromin    Miuretin),    spartein,   apocynum    cannabinum. 


400  THE  DISEASES  OF  CHILDREN. 

hellebore,  veratrum  album,  etc.  If  the  arterial  tension  is  too 
high,  owing  to  vaso-motor  irritation,  the  remedies  are  aurum, 
glonoin,  pilocarpin  and  iodide  of  sodium.  We  often  find 
cases  when  it  is  advantageous,  and  even  absolutely  necessary,  to 
alternate  or  combine  these  medicines  with  the  digitalis  group. 
In  several  cases  I  have  removed  cardiac  dropsy  with  weak  heart 
and  arterial  tension  by  giving  digitalis  and  glonoin  in  alterna- 
tion (one  drop  of  the  Ic  of  glonoin  with  one  to  three  drops  of 
the  tincture  or  Ix  of  digitalis),  every  four  or  six  hours. 

In  some  cases  it  is  absolutely  necessary  to  run  off  the  water 
through  the  bowels.  Then  we  must  resort  to  the  bitartrate  of 
potassa  (lo  to  20  grains  every  four  hours),  or  elaterium,  i  to  5 
grains  of  the  2x  ;  or  i  drachm  of  epsom  salts  by  the  mouth 
or  by  enema,  every  4  or  6  hours.  While  we  are  reducing  the 
dropsy  by  these  means,  cardiac  tonics  must  be  administered 
to  keep  up  the  failing  heart- 
Cardiac  dyspnea  is  one  of  the  most  distressing  symptoms 
of  valvular  disease.  It  is  often  so  severe  as  to  simulate  angina 
pectoris.  As  a  rule,  cactus,  digitalis,  kalmia  and  other  cardiac 
remedies  will  palliate  or  remove  it ;  but  there  are  cases  which 
require  immediate  relief,  as  the  patient  seems  in  danger  of 
dissolution.  Here  glonoin  acts  with  magical  promptness  and 
should  always  be  at  hand  to  be  given  by  the  attendant  when 
required. 

In  a  paper  on  "Glonoin  in  Heart  Disease,"  read  before  the 
British  Homeopathic  Society,  by  W.  Spencer  Cox,  M.D.,  he 
reports  several  cases  of  extreme  dyspnea  with  cyanosis,  uncon- 
sciousness, and  other  alarming  symptoms,  promptly  relieved 
by  a  single  dose  of  one  drop  of  the  Ix  dilution.  Others  were 
relieved  by  repeated  doses  of  one  drop  of  the  Ic  dilution.  The 
relief  was  due  to  the  power  possessed  by  this  drug  of  dilating 
the  arterioles. 

In  some  cases  of  extreme  arterial  tension,  with  powerful  ac- 
tion of  the  heart,  veratrum  viride  will  act  favorably.  -Quebracho 
will  greatly  relieve  continuous  dyspnea,  but  does  not  relieve  a 
paroxysm  as  quickly  as  glonoin.  Given  in  doses  of  5  to  10 
drops  of  the  tincture,  or  1-50  grain  of  its  alkaloid  (aspidosper- 
min),  every  3  or  4  hours,  it  renders  the  sufferer  from  dyspnea 
more  comfortable,  enabling  him  to  move  about  without  loss  of 
breath.  But  cases  will  occur  when  all  the  above  means  will 
fail  to  give  relief,  and  we  are  then  reluctantly  obliged  to  resort 
to  morphine,  preferably  by  hypodermic  injections.  In  very 
young  children  it  is  safer  to  give  on  the  tongue,  one  or  two 
grains  of  the  2x  trituration  every  two  or  three  hours.  Cocain 
in  the  same  doses  has  been  used  with  benefit.  If,  with  the 
extreme   dyspnea   and   high   arterial   tension,    the   patient    is 


THE  HEART— ENDOCARDITIS.  401 

constipated,  or  the  stools  are  pale  and  offensive,  mercurius  dulcis 
Ix  every  hour  until  purgation  ensues,  will  surely  give  relief. 

ENDOCARDITIS. 

Endocarditis  may  occur  in  the  fetus,  and  be  found  in  the 
new-born  infant.  It  is  stated  by  Rauchfous,  of  St.  Petersburg, 
that  he  saw  three  hundred  cases  of  fetal  endocarditis  in  several 
years.  It  is  a  little  singular  that  so  few  cases  have  been  re- 
ported in  this  country.  I  have  seen  and  recognized  but  three 
in  an  obstetric  practice  of  forty  years,  but  I  may  have  failed  to 
recognize  many  more. 

Endocarditis  before  birth  usually  affects  the  right  heart. 
Of  Rauchfous'  300  cases,  192  were  in  that  side.  It  has  been 
accounted  for  on  the  theory  that  the  increased  blood  pressure 
on  the  pulmonary  leaflets  was  the  cause.  It  is  a  fact  that  most 
congenital  cardiac  diseases  are  located  at  the  pulmonary  orifice. 

The  endocardial  hyperplasia  in  these  cases  is  generally  a  soft, 
red,  pedunculated  vegetation,  arranged  at  or  about  the  tricus- 
pid valves ;  sometimes  on  the  mitral,  and  very  rarely  on  the 
aorta  or  pulmonary  artery.  Arising  during  fetal  life,  they  may, 
if  the  child  survives,  disappear ;  but  they  are  apt  to  cause  such 
structural  changes  as  to  give  rise  to  cyanosis  at  birth. 

Endocarditis  arising  after  birth,  is  a  more  common  disease 
than  is  apprehended.  Very  few  physicians,  unless  they  have 
some  special  interest  in  this  subject,  ever  examine  the  heart  of 
an  infant  during  a  fever,  or  during  the  eruptive  diseases  of 
childhood.  Yet  a  fever  in  childhood  may  be  rheumatic,  and 
endocarditis  may  occur  during  measles,  scarlatina,  variola  or 
typhoid.  It  has  been  observed  as  a  concomitant  of  erythema 
nodosum.  It  is  a  common  accompaniment  of  chorea  ;  in  fact, 
few  cases  of  chorea  exist  without  an  endocardial  complication. 
Rarely,  it  may  be  idiopathic,  but  it  often  exists  as  the  first 
manifestation  of  inflammatory  rheumatism.  It  often  occurs  in 
pleurisy,  pneumonia,  Bright's  disease,  diphtheria  and  pyemia. 

Rheumatism,  however,  is  the  most  frequent  cause,  and  sub- 
acute rheumatism  in  childhood  is  very  often  unrecognized. 
Keating  and  Edwards  ("  Diseases  of  the  Heart  in  Children  ") 
believe  rheumatic  endocarditis  is  more  frequent  in  the  child 
than  in  the  adult.  Out  of  twenty-one  cases  of  rheumatism 
between  the  ages  of  fourteen  and  twenty,  Vernay  says  only 
one  escaped  endocarditis.  In  forty-seven  cases  in  children, 
D'Espine  found  only  ten  cases  in  which  the  sounds  of  the  heart 
were  perfectly  normal.  It  is  believed  that  the  younger  the 
patient,  the  greater  the  risk  of  the  heart  becoming  affected. 

Symptoms  and  Diagnosis. — Unless  the  physician  has  unusual 
D.  C— 26 


402  THE  DISEASES  OF  CHILDREN. 

intuitive  tact  in  the  diagnosis  of  diseases  of  children,  and  is  an 
adept  in  physical  examination  of  the  heart,  he  will  often  over- 
look an  endocarditis.  With  the  statement  of  the  causes  above 
mentioned  before  him,  he  ought  to  know  when  to  be  on  the 
lookout  for  the  disease — which  is  one-half  the  diagnosis.  If 
the  child  is  old  enough,  it  will  complain  of  a  pain  in  the  epigas- 
tric region  ;  they  will  put  the  hand  on  the  ensiform  cartilage  if 
you  ask  them  to  locate  the  pain.  Some  will  complain  of  pain 
in  the  left  axillary  region.  If  the  aorta  is  involved,  they  will 
complain  of  sharp  pain  along  its  course,  especially  on  move- 
ment. All  have  a  disinclination  to  lie  on  the  left  side,  and 
when  put  in  that  position  are  very  restless  and  anxious.  In 
very  young  children  close  attention  is  necessary  to  enable  us 
to  recognize  symptoms  of  cardiac  pain.  When  the  myocardium 
is  involved,  palpitation  is  a  prominent  symptom,  the  precardiaL 
distress  is  great ;  and  a  real  "  delirium  cordis" — a  tumultuous, 
violent  palpitation — obtains  as  the  disease  advances,  and  some- 
times ends  in  sudden  arrest  in  diastole.  The  temperature  is 
variable,  often  ranging  between  102°  and  104°  or  from  100°  \.o 
102°. 

The  pulse  is  at  first  accelerated,  later  it  is  feeble  and  dicrotic 
and  very  diflficult  to  count.  Respiration  is  greatly  affected,, 
dyspnea  appearing  early,  and  is  very  distressing.  Sudden  and 
alarming  dyspnea  appearing  in  the  course  of  almost  any  febrile 
disease  of  childhood  is  an  indication  of  serious  cardiac  implica- 
tion. Cough  is  sometimes  present  and  greatly  aggravates  the 
distress.  Nausea  and  vomiting  may  be  an  early  symptom  and 
become  violent,  and  towards  the  close  may  hasten  dissolution 
by  causing  exhaustion  and  inanition.  The  patient  may  sink 
into  an  apparent  typhoid  state  and  death  occur  from  heart  fail- 
ure in  diastole. 

Great  irregularity  and  tumultuous  action  of  the  heart  show 
increased  severity  of  the  disease,  and  the  strokes  of  the  apex 
against  the  chest  become  very  marked.  I  have  observed  in 
some  cases  great  distention  of  the  veins  of  the  neck  with  violent 
throbbing  of  the  arteries. 

Physical  Signs. — Percussion  is  of  no  value.  Palpation  may 
reveal  irregularity  of  the  heart's  action,  violent  throbbing,  and 
often  a  vibratory  thrill.  Palpation  will  give  the  exact  location 
of  the  apex-beat,  and  tell  us  when  the  left  ventricle  is  seriously 
involved,  for  then  its  location  will  be  changed,  or  may  disappear 
altogether  in  pericarditis  with  effusion.  It  will  also  promptly 
inform  us  when  myocarditis  occurs.  Auscultation  will  give 
us  better  information.  It  will  generally  reveal  a  systolic  bruit 
or  murmur  at  the  apex.  In  children  this  murmur  is  sometimes 
heard    with   startling   distinctness.     This   sound    may  not  be 


THE  HEART— ENDOCARDITIS.  408 

confined  to  the  apex,  but  may  be  transmitted  in  every  direc- 
tion, even  into  the  arteries.  It  is  sometimes  confounded  with 
hemic  murmur,  or  a  pericardial  bruit,  but  neither  are  so  loud 
and  distinct. 

An  accentuation  of  the  second  pulmonary  sound  should  be 
watched  for,  as  that  means  a  damming  back  of  the  blood  cur- 
rent through  the  lungs,  and  pulmonary  engorgement.  Engorge- 
ment of  the  right  heart  follows  such  engorgement,  and  then 
we  shall  generally  hear  a  tricuspid  murmur. 

Prognosis. — While  not  necessarily  fatal,  our  prognosis  should 
be  guarded.  A  complete  recovery  from  a  first  attack  is  rare ; 
there  will  remain  some  damage  which  will  invite  future  attacks, 
or  if  not  watched  will  result  in  chronic  valvular  troubles.  It  is 
especially  in  septic  diseases  of  children  that  serious  results  are 
most  to  be  feared  ;  for  the  products  of  exudation  or  ulceration 
and  emboli  may  be  carried  to  the  spleen,  kidneys,  or  lungs,  and 
cause  engorgement,  or  to  the  brain,  causing  paralysis. 

Ulcerative  endocarditis,  or  bacterial  endocarditis,  is  the  most 
dangerous  form.  It  may  be  caused  by  minute  abscesses  in  the 
valves  beneath  the  endocardium,  or  septic  exudation  processes; 
and  are  secondary  to  pyemia,  or  some  infection  poison  in  the 
blood. 

Treatment. — This  will  depend  upon  the  cause.  If  rheumatic, 
the  food  should  be  modified  so  as  to  prevent  an  acid  condition 
of  the  gastric  tract  and  its  resultant  acidity  of  the  blood.  If 
an  infant  not  at  the  breast,  the  milk  should  be  sterilized  and 
soda  or  some  alkali  added.  Even  in  nursing  children,  some 
alkaline  water  like  Vichy,  or  pure  soft  water  impregnated  with 
soda  should  be  given  to  drink.  Sugar  should  be  prohibited, 
and  all  starchy  food  not  malted — (subjected  to  a  prolonged 
second  baking).  Frequent  alkaline  baths  are  to  be  recommended. 

It  should  be  remembered  that  endocarditic  rheumatism  may 
occur  previous  to  any  other  rheumatic  manifestation.  If  a 
child  has  fever,  and  other  causes  are  eliminated,  always  examine 
the  heart.  Several  times  in  my  early  practice,  by  a  neglect  of 
this  rule,  I  have  found  an  endocarditis  when  it  was  too  late. 
If  we  find  the  heart  beating  rapidly,  forcibly,  and  the  pulse 
small  and  hard,  aconite  is  the  remedy ;  but  if  the  heart's  beat 
and  the  pulse  is  bounding  and  very  full,  give  veratrum  viride. 
These  two  will  control  any  fever  in  endocarditis  from  rheuma- 
tism, but  they  will  not  control  the  fever  of  septic  and  bacterial 
endocarditis.  If  the  patient  appears  to  have  stitching  pains, 
give  bryonia,  asclepias  tuberosa,  or  arnica.  If  there  are  other 
rheumatic  manifestations  in  the  joints  or  muscles,  salicylate  of 
soda  may  be  cautiously  given.  I  have  never  found  small  doses, 
one-tenth  to  one  grain   every  hour,  cause  any  cardiac  depres- 


404  THE  DISEASES  OF  CHILDREN. 

sion  ;  but  I  have  known  larger  doses  to  have  that  effect.  The 
heart  may  tolerate  them  while  the  febrile  excitement  is  at  its 
height,  but  will  not  when  the  fever  subsides.  The  salicylates 
should  be  stopped  as  soon  as  the  heart  becomes  weak,  irregular 
or  intermittent.  In  this  condition  of  the  heart,  cactus  ix,  digi- 
talis IX,  and  spartein  2x  are  the  chief  remedies — 5  to  10  drops 
of  the  former,  and  two  grains  of  the  latter,  every  three  or  four 
hours.  Convallaria  ought  to  be  useful  if  there  is  much  arterial 
throbbing  and  distension  of  the  veins  without  fever ;  but  Keat- 
ing says  he  never  saw  any  good  results  from  its  use.  As  it 
requires  to  be  given  in  a  low  dilution,  ix,  to  be  of  any  benefit, 
and  as  the  stomach  might  reject  it,  if  irritable,  I  would  advise 
the  use  of  convallaramin  in  doses  of  i-icx)  grain  in  sweetened 
water  every  three  hours.  If  the  urine  is  scanty,  red,  and  very 
acid,  the  salicylate,  benzoate,  or  bicarbonate  of  lithia  should  be 
given  in  the  ix  or  2x  trituration — 5  gr.  in  a  tablespoonful  of 
vichy  water  every  few  hours. 

Much  has  been  written  about  the  danger  of  high  tempera- 
ture in  cardiac  inflammations.  It  has  been  alleged  that  should 
it  go  above  104°  Fahr.,  degeneration  of  tissue  will  result.  I  do 
not  believe  the  temperature  ever  goes  above  104°,  except  in  ul- 
cerative endocarditis,  in  which  any  antipyretic,  which  forcibly 
lowers  the  temperature,  does  more  harm  than  good.  In  such 
cases,  I  have  found  phenacetin  ix  to  have  a  beneficial  effect 
in  rendering  the  patient  more  comfortable  and  preventing  heat- 
accumulation.  It  will  certainly  calm  the  nervous  agitation,  and 
the  suffering  from  extreme  heat,  better  than  aconite.  If  the 
patient  sweats  profusely,  stop  its  use  and  give  coffea  ix,  a  drop 
or  two  every  hour.  There  are  other  remedies  which  will  be 
indicated  during  the  course  of  the  disease :  namely,  spigelia  (a 
very  important  medicine),  spongia,  kalmia,  apis,  arsenicum,  col- 
chicum,  cimicifuga,  naja,  phosphorus,  scutellarin,  and  veratrum 
album.  In  treating  heart  failure,  with  cold  dusky  face  and 
extremities,  and  almost  imperceptible  pulse,  glonoin  will  exert 
wonderful  restorative  power — better  than  alcohol  or  ammonia  ; 
but  it  must  be  followed  closely  by,  or  alternated  with,  arsenicum, 
veratrum  album,  nux  vomica,  digitalis  or  cactus.  A  patient  with 
endocarditis  should  be  placed  at  perfect  rest,  not  taken  up  or 
carried  about,  but  soothed  by  the  mother  or  nurse  lying  down 
by  it.  The  room  should  be  dimly  lighted ;  no  excitement  or 
visitors  permitted,  and  no  talking  allowed  by  the  bedside.  If 
the  child  is  very  restless,  some  nervine,  like  scutellarin,  passi- 
flora,  coffea,  or  mono-bromide  of  camphor  should  be  given.  I 
have  had  good  results  in  such  condition  from  sulfonal  and  phe- 
nacetin, 2  to  10  grains  of  the  ix  in  infants  under  three  years, 
and  the  same  quantity  of  the  crude  drug  in  older  patients. 


THE  HEART— PERICARDITIS.  405 

In  the  discussion  on  a  paper  read  before  the  British  Homeo- 
pathic Society  (1893),  by  the  late  Dr.  A.  H.  Buck,  Dr.  Byres 
Moir  referred  to  his  hospital  experience  among  the  poor  children 
in  London.  He  saw  no  reason  why  pericarditis,  as  well  as  en- 
docarditis, should  not  be  congenital.  The  rheumatic  symptoms 
of  children  with  endocarditis  were  insignificant,  consisting  of  a 
few  aching  pains  ;  but  on  listening  to  the  heart  a  bruit  would 
be  heard.  There  was  scarcely  a  day  when  he  did  not  find  two 
or  three  children,  among  his  out-patients,  with  well-marked 
symptoms  of  endocarditis.  He  quoted  Dr.  V.  Green,  who 
stated  that  endo-  and  pericarditis  are  found  often  in  very  young 
children,  and  as  the  age  increases  the  percentage  becomes  less. 
Dr.  Moir  said  the  form  of  pericarditis  in  children  was  very  in- 
teresting. He  had  seen  several  cases  where  the  pericardium 
was  totally  adherent.  These  cases  were  very  often  associated 
with  chorea.  He  had  found  aconite  acted  well  in  the  first  stage, 
and  bryonia  or  mercurius  in  the  second  stage  of  effusion.  Dr. 
Blakely  said  he  had  frequently  seen  cases  of  congenital  endo- 
carditis with  hypertrophy.  In  these  cases  there  were  pericar- 
dial adhesions,  apex-beat  two  and  one-half  inches  outside  the 
nipple  line,  and  the  action  of  the  heart  tumultuous  and  irregular 
to  the  last  degree.  The  consensus  of  opinion  relating  to  treat- 
ment was  that  aconite,  bryonia,  and  mercurius  were  very  useful 
remedies.  Dr.  Wyman  Thomas  had  seen  good  results  from 
salicylate  of  soda  when  aconite  and  bryonia  failed.  In  several 
cases  he  gave  ten  grains  every  hour  until  the  pain  was  relieved. 
Dr.  Lough  highly  praised  veratrum  viride.  Dr.  Clifton  said  we 
should  not  neglect  to  study,  in  cases  of  rheumatism  of  the 
heart,  kalmia,  arnica,  colchicum,guaiacum,  lycopodium  and  san- 
guinaria.  Dr.  Edward  Blake  entertained  no  doubt  of  the  pos- 
sibility of  intra-uterine  pericarditis.  If  anything  interfered  with 
the  placental  functions — and  the  after  birth  is  the  only  fetal 
emunctory — toxines  could  be  stayed  in  the  fetal  system,  and  any 
or  many  of  the  recognized  septic  invasions  would  take  place. 

I  (Hale)  believe  that  if  closer  investigations  were  made  into 
the  causes  of  death  in  still-born  children,  or  those  who  die 
shortly  after  birth,  evidence  would  be  found  that  the  heart  had 
been  diseased  in  utero  from  some  disease  of  the  mother, 
namely  :  rheumatism,  Bright's  disease,  gonorrhea,  syphilis,  or 
pyemia.     Dr.  Blake's  suggestion  was  eminently  practical. 

PERICARDITIS. 

Pericarditis  is  an  inflammation  of  the  pericardium  or  serous 
covering  of  the  heart.  This  covering  is  composed  of  two 
layers,  the  visceral  and  parietal ;  both  may  be  inflamed.     As 


406  THE  DISEASES  OF  CHILDREN. 

a  rule  it  becomes  general ;  only  very  rarely  does  it  exist  un- 
complicated with  endocarditis  and  myocarditis.  It  is  believed 
by  many  authorities  that  pericarditis  is  more  common  in  the 
infant  than  in  the  adult.  There  is  no  doubt  that  it  is  frequently 
unrecognized,  for  it  is  a  fact  that  post-mortem  examinations  re- 
veal its  existence  when  it  was  not  believed  to  exist  during  life. 

Rheumatism  is  without  doubt  the  principal  cause  of  pericar- 
ditis ;  it  has  been  observed  in  the  newly-born  infant.  It  may 
be  caused  by  typhoid  fever,  scarlatina,  measles,  variola,  the 
retrocession  of  eruptions,  and  Bright's  disease.  Some  cerebral 
affections  in  children  may  coincide  with  pericarditis.  Rillet  and 
Barthez,  in  300  cases  of  death  by  tuberculosis  in  children, 
observed  ten  cases  of  deposition  of  tubercles  in  the  pericar- 
dium with  acute  inflammation  of  that  tissue. 

Sibson  reports  that  out  of  326  cases  of  rheumatism,  63  had 
pericarditis,  and  25  of  these  were  from  sixteen  to  twenty  years 
of  age.     All  the  fatal  cases  were  under  twenty  years  of  age. 

Symptoms. — Like  endocarditis,  pericarditis  may  be  acute  or 
chronic,  primary  or  secondary.  The  symptoms  are  generally 
masked,  latent,  and  ill-defined  during  the  early  stages.  A 
symptomatic  diagnosis  in  the  child  is  beset  with  numerous  dif- 
ficulties. The  marked  local  pain  observed  in  the  adult  is  not  so 
well  defined  in  the  child.  It  is  not  as  able  to  point  out  the 
seat  of  the  pain.  It  may  be  mistaken  for  pleurisy  or  pleuro- 
pneumonia of  the  left  side.  If  there  is  a  rheumatism  or  eruptive 
fever  present,  we  shall  be  better  able  to  make  a  diagnosis.  The 
cough,  respiration,  pain  on  movement,  and  complaints  of  pain 
during  these  actions,  may  arouse  our  suspicions  ;  but  we  cannot 
be  certain  of  the  existence  of  pericardial  inflammation  without 
the  aid  of  auscultation,  and  this  will  not  greatly  aid  us  until 
sufficient  lymph  has  been  exuded  to  roughen  the  surfaces  of 
the  pericardium,  or  an  effusion  has  formed  with  its  undoubted 
characteristic  symptoms.  Then  a  diagnosis  can  be  surely  made. 

Keating  and  Edwards  ("  Diseases  of  the  Heart  in  Children  ") 
give  the  following  local  physical  signs :  "  We  may  then  rely 
first  upon  the  friction  murmur  and  later  upon  the  muffled 
heart-sounds,  which  may  eventually  almost  entirely  disappear, 
especially  at  the  apex,  the  sounds  at  the  base  being  heard  until 
the  fluid  completely  distends  the  pericardial  sac  ;  the  friction- 
sound  or  murmur  will  also  linger  until  this  condition  pertains. 
This  friction-sound  is  to  and  fro,  that  is,  synchronous  with  the 
systole  and  the  diastole,  the  former  causing  the  inflamed  and 
roughened  surfaces  to  closely  approximate,  the  latter  to  recede. 
We  must  bear  in  mind  that  the  heart  of  a  child  is  much  nearer 
the  auscultator's  ear  than  that  of  an  adult ;  forgetting  this  point, 
auscultation  is  apt  to  be  very  confusing  and  misleading  in  the 


THE  HEART— PERICARDITIS.  407 

young.  The  friction-sound,  if  it  exists,  will  rapidly  become 
more  apparent,  as  in  the  child  the  membrane  is  formed  with 
great  rapidity.  In  pericarditis  the  bruit  or  murmur  which  is 
heard  over  the  precordia  may  have  two  sources  of  origin :  it 
may  be  due  either  to  an  intercurrent  endocarditis  or  to  peri- 
carditis alone  and  uncomplicated.  A  pericardial  murmur  in  a 
child  may  closely  simulate  an  endocardial  bruit.  The  special 
and  diagnostic  characters  of  a  pericardial  friction  murmur  are 
as  follows : 

"  It  is  usually  basal,  or  directly  over  the  body  of  the  heart. 
The  murmur  is  almost  always  double,  or  to  and  fro. 

"  It  is  not  transmitted  into  the  vessels  and  circulation,  but 
may  be  heard  in  a  child  over  a  much  larger  precordial  area  than 
in  the  adult.  It  is  but  rarely,  however,  heard  over  the  posterior 
left  thorax.  The  murmur,  particularly  in  the  young,  will  be 
altered  by  the  position  of  the  patient  in  being  intensified  as  the 
subject  leans  forward,  and  rendered  less  audible  during  full 
inspiration  or  in  the  reclining  posture.  The  effusion  is  apt  to 
arise  somewhat  rapidly,  and  by  inspection  we  may  note  a  peri- 
cardial bulging,  which,  in  children,  is  marked,  and  arises  early. 
The  ribs  being  flexible  and  the  thorax  small,  the  bulging  be- 
comes more  apparent.  A  rachitic  deformity  of  the  chest  must 
be  differentiated  from  the  bulging  due  to  an  effusion. 

"  The  distention  of  the  pericardium  will  cause  upward  dis- 
placement of  the  apex-beat.  This  is  coincident  with  the  for- 
mation of  the  fluid,  and  is  proportionate  to  its  quantity.  In 
cases  where  any  amount  of  effusion  has  been  poured  out,  the 
apex  may  be  displaced  one  or  more  interspaces.  The  cardiac 
impulses,  like  that  of  an  adult  under  similar  conditions,  will  be 
materially  diminished.  The  symptoms  on  palpation  are  about 
the  same  in  both  the  child  and  the  adult. 

The  general  symptoms  are  as  follows :  The  disease  may  be 
ushered  in  by  chill,  fever,  cerebral  symptoms,  such  as  delirium 
or  choreic  movements,  followed  by  somnolence.  The  pulse  at 
first  may  be  regular,  but  as  the  cardiac  muscle  becomes  weaker 
the  circulation  becomes  irregular,  and  the  radial  pulsation  feeble 
and  intermittent.  Later  the  pulse  becomes  small,  irregular 
and  intermittent ;  there  spiration  is  much  embarrassed  ;  extreme 
dyspnea  may  arise,  and  even  apnea  appear,  with  actual  as- 
phyxia." The  temperature  increases  with  the  severity  of  the 
disease  and  in  scarlatinal  pericarditis  I  have  known  it  to  reach 
1 06°  Fahr. 

Prognosis. — Recovery  from  pericarditis  is  common.  It  is 
not  as  fatal  as  endocarditis,  but  adhesions  may  form  and  cause 
dilatation  of  the  cavities  of  the  heart.  This  disease  has  been 
known  to  occur  in  the  fetus  and  new-born.     In  children  dying 


408  THE  DISEASES  OF  CHILDREN. 

thirty-six  hours  after  birth  pericardial  adhesions  have  been 
found.  Pyemic  pericarditis  may  follow  inflammation  of  the 
umbilical  cord. 

Treatment. — The  treatment  of  pericarditis  calls  for  many  of 
the  medicines  used  in  endocarditis,  especially  aconite,  veratrum 
viride,  bryonia,  asclepias  tuberosa,  apis  and  salicylate  of  soda. 
In  addition,  especially  when  effusion  of  lymph,  or  exudation 
has  occurred,  we  shall  find  iodide  of  arsenic,  iodide  of  potash, 
apocynum  cannabinum,  and  iodine  frequently  indicated.  To 
maintain  the  strength  of  the  heart-muscle  we  are  impera- 
tively obliged  to  resort  to  cactus,  digitalis,  caffein  and  spar- 
tein,  and  they  must  be  used  in  physiological  doses,  namely, 
one  or  two  drops  of  the  tincture,  or  one  grain  of  the  ix  tritura- 
tion every  two  or  three  hours.  The  same  hygienic  measures 
recommended  in  endocarditis  should  be  adopted. 

The  treatment  of  pericarditis  with  effusion  combines  medical 
and  surgical  measures.  As  soon  as  percussion  and  auscultation 
shows  the  presence  of  fluid  in  the  pericardial  sac,  the  kidneys 
should  be  stimulated  to  action,  and  at  the  same  time  the  mus- 
cular structure  of  the  heart  should  be  toned  up.  This  is  best 
accomplished  by  the  use  of  digitalis  and  apocynum  canna- 
binum. Both  have  a  similar  action  on  the  heart  and  kidneys. 
The  dose  of  digitalis  may  be  stated  to  be  one  drop  for  every 
two  years  of  the  child's  age,  namely,  one  drop  every  three  hours 
for  a  child  of  one  year  and  six  drops  for  a  child  of  twelve  years. 
If  the  tincture  of  apocynum  is  used,  the  same  dose  is  efficient. 
I  prefer  the  decoction  prepared  after  my  formula  in  "  New 
Remedies  ;"  of  this,  ten  drops  is  equivalent  to  one  drop  of  the 
tincture.  Spartein  is  often  very  useful.  The  dose  of  this  is 
one  grain  of  the  icevery  two  hours  for  an  infant  under  two 
years  of  age,  increasing  one  grain  for  each  year  of  the  child's 
age.  If  these  medicines  do  not  keep  up  the  action  of  the 
heart,  alternate  them  with  nux  vomica  ix,  or  strychnia  3X.  If 
the  bowels  are  constipated  I  should  not  hesitate  to  give  i-ioo 
grain  of  elaterin  every  four  hours,  or  enough  to  cause  watery 
motions.     This  will  aid  in  relieving  the  cardiac  dropsy. 

In  no  other  disease  is  it  so  important  to  keep  the  patient 
absolutely  quiet,  even  if  we  have  to  tie  the  child  to  the  bed  or 
cradle.  Death  has  occurred  suddenly  from  allowing  the  child 
to  sit  up  in  bed,  or  turn  suddenly  from  side  to  side.  Stimu- 
lants should  be  given  ;  the  best  are  champagne,  tokay  and 
brandy. 

Paracentesis  pericardii. — This  has  been  resorted  to  when 
medicines  will  not  cause  absorption  of  the  effusion,  and  when 
there  is  great  danger  of  heart  failure.  The  surgeon  should  not 
wait  too  long,  as  delay  is  apt   to  set  up  fatty  degeneration  of 


THE  HEART— MYOCARDITIS.  409 

the  muscular  wall  of  the  heart  and  dilatation  of  its  cavities. 
"  Use  an  aspirator  with  a  vacuum  jar,  and  a  delicate  double 
canula.  The  innermost  portion  may  be  either  a  solid  needle 
or  a  needle-pointed  tube,  either  of  which  are  to  be  withdrawn, 
the  former  entirely,  and  the  latter  until  its  point  is  sheathed." 
— Keating. 

The  point  selected  to  aspirate  is  where  there  is  the  least 
danger  of  wounding  the  heart-muscle.  "  This  is  either  in  the 
left  costo-ziphoid  angle,  pushing  the  trocar  upward  toward  the 
heart ;  or  by  inserting  the  trocar  at  the  fifth  interspace,  about 
where  the  apex  should  normally  be  situated  when  it  is  not 
displaced." — Keating. 

For  further  minute  direction  refer  to  Keating  and  Edwards, 
p.  88,  also  Table  of  Cases,  p.  90. 

MYOCARDITIS. 

This  disease  is  generally  so  complicated  and  associated  with 
endo-  and  pericarditis,  and  so  difficult  to  diagnose  during  life, 
that  it  needs  only  brief  mention. 

Dr.  Blache  classifies  as  follows  the  diseases  with  which  myo- 
carditis may  be  associated : 

(    General  illness. 
General  diseases <    Grave  fevers — variola. 


Local  causes 


Alteration  in  circulation. 


(    Cachexia. 

{Diseases  of  pericardium. 
Diseases  of  endocardium. 
Diseases  of  vessels  of  heart. 
Abscesses  or  tumors  of  heart. 

f  Embolism. 

J  Thrombosis. 

I  Atheroma. 

(^  Edema. 


Symptoms. — The  symptoms  of  myocarditis  depend,  of  course, 
on  its  form  and  the  extent  to  which  the  disease  has  progressed. 
When  the  lesion  is  small  and  limited,  few,  if  any,  symptoms 
exist  at  all  by  which  a  clinical  diagnosis  can  be  made.  If,  how- 
ever, the  lesion  is  extensive,  then  we  meet  those  symptoms 
which  we  all  recognize  as  characteristic  of  heart-disease,  as 
dyspnea,  palpitation,  dropsy,  visceral  derangement,  or  precor- 
dial  discomfort ;  nervous  symptoms  are  peculiarly  liable  to  arise 
early  in  these  cases. 

Most  cases  of  myocarditis  pursue  a  long  course ;  should, 
however,  an  aneurism  develop,  the  case  will  be  more  rapid.  In 
other  cases  sudden  death  may  occur  from  cardiac  arrest.  The 
most  usual  termination,  is,  however,  by  dropsies,  pulmonary 
complications,  or  by  exhaustion. 


410  THE  DISEASES  OF  CHILDREN. 

Traumatism  may  cause  myocarditis,  and  rapidly  prove  fatal. 
A  case  is  recorded  of  a  child  aged  twelve,  who  was  kicked  over 
the  heart  and  died  shortly  afterwards  with  abscesses  in  the 
heart-muscle. 

"  The  diagnosis  is  indeed  difficult,  and  in  many  cases  quite 
impossible ;  this  is  particularly  true  of  the  so-called  cerebral 
form  of  myocarditis,  which  is  especially  noticeable  during  early 
life.  Burnheim  reports  several  cases  in  children.  A  child  aged 
twelve,  with  febrile  symptoms,  delirium,  agitation,  and  dilated 
pupils,  died  four  days  after  admission.  Child  never  had  a  pain 
in  the  chest,  or  heart-irregularity,  or  cardiac  palpitation.  At 
the  post-mortem  the  heart  was  of  a  deep-red  color,  softened,  and 
easily  torn  ;  in  the  walls  of  both  ventricles  a  number  of  abscesses 
were  found,  with  quite  a  number  beneath  the  visceral  layer  of 
the  pericardium  ;  auricular  muscle  softened.  Heart-clots  were 
numerous.  It  is  a  clinical  nicety  to  differentiate  between  cases 
of  subacute  or  chronic  myocarditis,  and  the  heart  that  accom- 
panies emphysema,  or  that  seen  with  renal  disease,  or,  again, 
the  heart  that  is  altered  by  fatty  degeneration." — Keating. 

The  chief  indication  is  to  prevent  heart  failure.  In  cases  of 
young  children  with  delicate  stomachs  I  would  advise  the  use 
of  the  alkaloids  of  the  cardiac  remedies,  for  the  small  doses  re- 
quired are  much  more  easily  administered  and  retained.  Adon- 
din,  convallarin,  digitalin,  spartein,  strychnin,  and  cactina  in 
doses  of  i-iooo  of  a  grain  (3x)  are  quite  efficient  if  frequently 
repeated.  I  must  here  refer  again  to  the  necessity  of  absolute 
rest.  Unless  we  can  accomplish  this,  no  medicine  can  relieve 
or  cure  our  little  patient.  In  cases  of  threatened  heart  failure 
from  overexertion,  give  glonoin  on  the  tongue.  If  abdominal 
distension  interferes  with  the  action  of  the  heart,  empty  the 
intestines  as  quickly  as  possible. 

SYMPTOMATIC   INDICATIONS   FOR   MEDICINES   IN   DISEASES 
OF   THE   HEART. 

[Only  the  most  important  are  here  mentioned.  The  well  proven  remedies 
are  mostly  omitted,  as  their  symptoms  are  familiar  to  all]. 

Aconite. — Fever  with  great  restlessness  and  anxiety  ;  high 
temperature  ;  hot,  dry  skin  ;  thirst ;  pulse  small,  hard  and  quick  ; 
stitches  in  the  region  of  the  heart  with  sudden  crying  out, 
moaning  and  tears ;  rapid  and  painful  respiration.  Indicated 
in  acute  pericarditis,  endocarditis  and  myocarditis. 

Arsenicum. — Fever  of  low  type,  with  intense  thirst ;  some- 
times unquenchable,  at  others  drinking  only  a  little  at  a  time ; 
temperature  sometimes  high,  sometimes  sub-normal  ;  uncontrol- 
lable restlessness  and  anxiety,  great  dyspnea — cannot  lie  down  ; 


IN  Die  A  TIONS  FOR  MEDICINES.  411 

feeble,  irregular  pulse.  Indicated  in  ulcerative  endocarditis; 
inflammation  of  the  valves,  during  the  progress  of  Bright's  dis- 
ease, or  typhoid  fever ;  dilatation  of  the  heart  with  local  or 
general  edema. 

Adonis  Vernalis. — Indicated  in  chronic  valvular  disease,  or 
dilation  with  hypertrophy, with  general  anasarca, dyspnea,  scanty 
urine,  cardiac  dyspnea,  pulse  feeble,  irregular  or  intermittent. 
In  such  cases  it  acts  as  a  cardiac  tonic  and  diuretic  when  digi- 
talis has  failed.  Dose  one  to  ten  drops  of  the  ix  in  infants 
repeated  every  two  hours.  In  older  patients  one  to  five  drops 
of  the  tincture. 

Apium  Virus. — Sudden  general  edema,  with  suppression  of 
urine  occurring  during  pericarditis,  scarlatina,  or  from  a  sudden 
cold  after  being  overheated.  Stinging  pain  in  the  region  of  the 
heart,  dyspnea,  very  rapid  breathing,  with  intense  mental  anx- 
iety.    Always  prescribe  the  trituration — 2x  to  6x. 

Amyl  Nitrite. — Sudden  fainting;  cardiac  failure;  with  col- 
lapse, pulselessness,  or  feeble,  irregular,  almost  imperceptible 
pulse  ;  cyanosis,  cold  face  and  extremities ;  dusky  lips  and 
fingers,  cold  sweat.  A  few  drops  on  a  handkerchief  placed  be- 
fore the  nose  and  mouth.  As  soon  as  a  full  pulse  appears 
suspend  the  inhalation.  In  desperate  cases  administer  it  hypo- 
dermatically  (one  drop  mixed  with  fifteen  of  water). 

Apocynum  Cann. — This  root  contains  a  substance  the  phys- 
iological and  therapeutic  effect  of  which  is  said  to  resemble 
that  of  digitalis,  except  that  it  does  not  possess  the  cumulative 
power  of  the  latter. 

Administered  in  the  form  of  the  fluid  extract  in  doses  of  ten 
to  fifteen  drops,  three  times  daily,  Canadian  hemp  is  said  to 
render  the  pulse  slower,  and  at  the  same  time  fuller  and 
stronger.  In  cases  of  dilatation  of  the  heart,  it  is  stated,  it  rap- 
idly causes  a  decrease  in  the  area  of  cardiac  dullness ;  and  in 
patients  affected  with  valvular  lesions,  it  renders  diuresis  man- 
ifestly more  active,  does  away  with  the  edema,  and  determines 
the  disappearance  of  palpitation  and  dyspnea.  The  remedy  is 
usually  well  borne  by  the  patients  when  administered  in  the 
stated  doses ;  the  only  disagreeable  effect  is  occasionally  a  feel- 
ing of  throbbing  of  the  blood-vessels  in  the  head. 

Dr.  Glinsky  reports  its  effect  on  himself ;  being  affected  with 
hypertrophy  of  the  left  ventricle  with  dilatation  of  the  heart, 
manifested  in  paroxysms  and  accompanied  by  a  systolic  mur- 
mur at  the  apex  (symptom  of  mitral  regurgitation),  precordial 
angor  and  dyspnea,  increased  by  the  slightest  movement. 
Under  the  influence  of  the  fluid  extract  of  Canadian  hemp,  he 
found  that  all  the  morbid  phenomena,  both  subjective  and  objec- 
tive, subsided  in  two  days ;  the  pulse,  which  beat  at  the  rate  of 


412  THE  DISEASES  OF  CHILDREN. 

no  per  minute,  fell  to  80;  and  the  dyspnea  was  so  completely 
suppressed  that  even  a  lengthy  walk  did  not  cause  the  slightest 
feeling  of  oppression. 

In  cases  of  valvular  lesions  of  the  heart,  with  symptoms  of 
hyposystolia,  in  which  strophanthus,  adonis  vernalis,  and  con- 
vallaria  majalis  had  been  administered  without  effect,  Dr.  G., 
in  a  few  days,  effected,  by  means  of  Canadian  hemp,  the  disap- 
pearance of  edema  and  dyspnea,  as  well  as  marked  reduction 
of  the  area  of  cardiac  dullness. 

It  has  been  noticed,  for  many  years,  by  myself  and  others, 
that  when  this  drug  was  given  for  dropsy,  the  condition  of  the 
heart  greatly  improved.  The  fact  that  apocynin^  its  active 
principle,  acts  like  digitalin,  accounts  for  that  result.  Like  digi- 
talis, the  infusion  or  decoction  often  acts  better  than  the  tinc- 
ture. For  children,  five  to  ten  drops  of  the  ix  every  two  hours, 
or  double  that  quantity  of  the  decoction,  acts  very  happily. 

Glonoin. — Is  applicable  in  cases  when  the  emergency  is  not 
as  urgent,  although  if  given  hypodermatically  it  acts  almost 
immediately.  The  indications  are  the  same  as  for  amyl.  Both 
dilate  the  arterioles  and  allow  the  blood  to  flow  freely  from  the 
central  portions  of  the  body  to  the  periphery.  If  given  when 
the  capillary  circulation  is  arrested  or  stagnated,  either  from 
vaso-motor  spasm  or  cardiac  failure,  the  terminal  vessels  dilate 
and  the  congested  heart  is  emptied  of  the  blood  in  its  cavities, 
which  it  was  not  strong  enough  to  expel.  No  stimulant  acts 
as  quickly  and  beneficially  in  the  cardiac  or  pulmonary  diseases 
of  children.  Its  timely  use  will  ward  off  dangerous  conditions 
approaching  collapse. 

Aurum. — Is  primarily  indicated  in  acute  congestion  of  the 
heart,  great  blood  vessels,  and  brain  ;  also  in  endocarditis,  when 
palpitation,  suffocative  anguish,  and  constriction  of  the  chest 
are  present,  indicating  diseases  of  the  aortic  valves. 

Cactus. — Dyspnea,  anxiety,  screaming  with  fear,  sensation  of 
an  iron  hand  grasping  the  heart,  with  constriction  of  the  whole 
chest.  The  pulse  may  be  full,  bounding,  but  soft,  with  some 
arterial  congestion  of  the  head ;  or  pulse  small,  weak,  irregular, 
or  intermitting.  Primarily  indicated  in  small  doses  in  acute 
congestions,  and  cardiac  inflammations  in  the  2x  to  6x  dilutions. 
Secondarily  indicated  in  hypertrophy  with  dilatation,  all  the  val- 
vular lesions  when  the  heart  is  weak,  with  concomitant  dropsy ; 
hemorrhages,  and  cardiac  dyspnea — in  doses  of  five  to  twenty 
drops  of  the  ix  or  tincture,  three  or  four  times  daily. 

These  directions  for  dose  are  not  theoretical,  but  deductions 
from  my  experience  in  the  use  of  the  drug. 

Convallaria. — Violent  palpitation ;  pulse  large  and  empty  ; 
throbbing   and   visible   pulsation    of    the    arteries   (Corrigan's 


INDICATIONS  FOR  MEDICINES.  413 

disease),  or  small,  irregular,  weak,  and  intermitting;  distressing 
dyspnea ;  pain  about  the  heart  radiating  into  the  left  arm,  and 
down  along  its  internal  aspect  into  the  fingers.  Dropsy  with 
general  or  local  edema ;  mental  depression,  melancholy  or  hys- 
terical symptoms.  Suitable  to  infants  after  scarlatina,  young 
girls  at  puberty  who  suffer  from  reflex  cardiac  neuroses ;  pseu- 
do  angina  pectoris  (in  which  the  dose  should  be  small,  2x  to  4x). 
Valvular  disease,  especially  aortic,  or  when  the  right  heart  is 
dilated  ;  in  which  the  dose  should  be  gtts  i  to  v.  of  the  tincture. 

Coffea  and  Caffein. — CofTea  cruda  is  an  invaluable  remedy 
in  neuroses  of  the  heart  in  infants  and  young  children  and  girls. 
The  subjects  in  whom  it  is  indicated  are  the  offspring  of  neuro- 
tic parents  who  suffer  from  the  effects  of  social  dissipation  or 
abuse  of  stimulants.  The  little  patients  are  sleepless,  irritable, 
affected  unpleasantly  by  unusal  noises  or  emotions.  When 
sleepless  or  excited  it  will  be  observed  that  the  hearts  action  is 
rapid,  violent,  and  often  irregular.  In  such  cases  the  3x  or  6x 
dilution  will  act  in  the  happiest  manner.  Caffein  in  the  6x  or 
I2X  will  be  equally  suitable. 

Caffein  causes  secondarily — i.  e.,  in  toxic  doses — paralysis  of 
the  heart  in  diastole,  if  its  primary  contraction  in  systole  is  not 
fatal.  It  is  therefore  valuable  in  physiological  doses  as  a  cardiac 
tonic  when  the  heart  is  suddenly  threatened  with  paralysis. 
The  hearts  of  children,  during  peri-  and  endocarditis,  are  more 
prone  to  paralysis  than  those  of  adults.  It  follows  well  amyl  and 
glonoin,  after  the  immediate  danger  is  passed.  In  such  in- 
stances under  the  use  of  the  ix  or  2x  in  three  to  five  grain  doses 
every  hour,  the  heart  soon  regains  its  force,  and  if  dropsy  is 
present,  the  kidneys  soon  resume  their  normal  function. 

Carpain. — This  is  an  alkaloid  obtained  from  the  leaves  of 
the  carica  papaya,  or  "  paw  paw"  tree  of  Florida  and  the  trop- 
ics. It  is  from  the  fruit  of  this  tree,  which  looks  like  a  small 
melon,  that  the  digests  variously  called  papayotine,  papaine  and 
papoid  are  made.  It  is  said  that  this  digestive  principle  is 
found  also  in  the  leaves  and  bark,  but  the  juice  of  the  leaves 
cannot  be  inocuous  if  carpain  is  found  in  it,  for  it  is  a  heart 
poison  like  digitalin. 

Dr.  Von  Orfele,  who  experimented  extensively  with  car- 
pain, found  it  to  act  like  the  digitalis  group  of  cardiac  drugs. 
In  doses  of  three-eighths  grain  per  diem  it  caused  similar  dis- 
turbances in  the  rhythm,  blood  pressure  and  the  pulse  charac- 
teristic of  digitalis.  He  also  found  that  carpain  was  the 
only  congener  of  digitalis  that  could  be  used  hypodermatically 
without  causing  irritation  and  abscesses.  The  cardiac  diseases 
for  which  it  has  been  found  most  useful  are  aortic  insufficiency 
and  stenosis.     In  doses  of  one-tenth  grain  daily  it  effected  reduc- 


414  THE  DISEASES  OF  CHILDREN. 

tion  of  the  frequency  of  the  pulse,  also  alleviation  of  the  dyspnea, 
and  doubled  the  quantity  of  urine.  This  means  doses  of  one  or 
two  grains,  of  the  2x  trituration,  repeated  several  times  a  day. 
Or,  it  is  probable  that  the  writer  means  that  the  one-tenth 
grain  be  given  at  a  single  dose,  as  the  one-sixtieth  grain  of 
digitalin  is  now  often  given  and  allowed  to  act  for  a  day  or  two. 

Coronillin, — The  glucoside  from  coronilla  scorpioides,  an 
European  plant,  is  equal  in  power  to  digitalin.  Not  sufficient 
experiments  have  been  made  on  warm-blooded  animals  or  prov- 
ings  on  men  to  enable  us  to  decide  just  how  it  affects  the 
heart.  We  only  know  from  empirical  data  gained  from  its  use 
in  dropsy  from  cardiac  disease,  that  it  causes  profuse  diuresis, 
followed  by  great  improvement  in  the  condition  of  the  heart. 
One  authority  who  has  experimented  with  it  says  it  differs  from 
digitalis  in  not  causing  as  much  contraction  of  the  arterioles  as 
digitalis.  The  dose  is  one  or  two  grains  of  the  second  or  third 
trituration. 

Digitalis. — As  thoroughly  as  the  best  physicians  of  all 
schools  are  supposed  to  understand  the  action  of  digitalis,  it  is 
still  often  used  inappropriately.  It  is  too  often  the  routine 
habit  to  give  this  drug  when  some  valvular  lesion  is  discovered, 
and  there  is  at  the  same  time  a  quick,  irregular  or  intermit- 
tent action  of  the  heart.  But  this  is  not  an  indication  for  its 
use,  unless  the  pulse  is  soft  and  there  is  unmistakably  2,  low 
tension  in  the  arteries  with  venous  stasis.  Here  it  will  always 
act  favorably ;  but  if  there  is  high  arterial  tension,  or  even 
normal  tension,  material  doses  will  act  unfavorably. 

If  the  primary  symptoms  of  digitalis  are  present — viz.:  rapid 
and  strong,  or  quick  and  hard  beating  of  the  heart,  with  high 
tension  pulse,  digitalis  is  indicated  only  in  infinitesimal  doses, 
but  I  confess  I  have  never  seen  good  effects  from  its  use  in 
such  cases  ;  aconite  always  gives  me  better  results.  But  if  the 
pulse  is  feeble,  small,  or  large  but  soft,  or  "  empty,"  showing 
very  low  arterial  tension,  (which  means  a  thin  or  weak  heart) 
then  digitalis  in  physiological  doses,  will  nearly  always  act  well. 
By  physiological  doses  I  mean  for  children,  one  to  ten  drops 
of  the  IX  dilution  or  ix  trituration.  If  the  infusion  is  used  the 
dose  is  ten  to  twenty  drops,  graduated  according  to  the  age  of 
the  patient.  Rely  more  on  the  objective  than  the  subjective 
symptoms.  If  the  child  is  dropsical  the  attention  to  the  state 
of  arterial  tension  is  of  great  importance.  If  the  tension  is 
above  normal  in  the  pulse,  it  is  high  in  the  kidneys,  and  then 
digitalis  will  not  act  as  a  diuretic  in  material  doses,  for  it  will 
increase  the  tension  in  the  renal  vessels,  and  sometimes  sup- 
press the  urine.  Too  high  or  too  low  tension  in  the  renal 
arterioles  will  cause   dropsy.     Too  high  tension   is   rendered 


INDICA  TIONS  FOR  MEDICINES.  415 

normal  by  aconite,  glonoin,  aurum,  veratrum  viride  and  a  few 
others.  Too  low  tension  is  benefited  by  digitalis,  caffein, 
strophanthus,  cactus,  adonis,  spartein  and  nux  vomica. 

Erythrophlein,  (casca)  has  been  found  to  constrict  the  arte- 
rioles and  cause  a  higher  tension  than  digitalis,  and  may  be  used 
when  digitalis  is  indicated,  but  is  not  well  borne  by  the  stom- 
ach even  in  small  doses.  The  dose  of  casca  for  children  need 
not  exceed  five  to  ten  drops  of  the  ix  or  2x  dilution  repeated 
every  two  or  three  hours  until  its  favorable  effects  appear. 

Oleander. — It  sometimes  occurs  that  during  the  treatment 
of  valvular  disease,  or  a  weak,  irritable  heart  in  children,  there 
will  set  in  a  lientery  which  rapidly  reduces  the  strength  of  the 
patient.  We  have  in  such  cases  an  admirable  remedy  in  olean- 
der. Besides  the  evacuations  of  undigested  food  ,  the  sudden 
movements  of  the  bowels  after  taking  food,  which  characterizes 
lientery ,  we  find  other  important  symptoms,  viz.:  great  pros- 
tration, stupor,  dilated  pupils,  thick  speech,  anxiety  about  the 
heart  with  fear  and  trembling,  pulse  small,  irregular,  intermit- 
ting, often  sinking  to  a  thread,  and  suffocating,  choking  sensa- 
tions. Sometimes  the  heart  beats  slow,  at  other  times  rapid 
and  violent.  For  these  symptoms  the  2x  or  3X  dilutions  are 
appropriate. 

Spartein. — This  drug  which  resembles  convallaria  and  cactus, 
has  one  advantage  which  they  do  not  possess.  It  acts  more 
rapidly  than  any  other  cardiac  sedative  and  tonic.  Its  quieting 
effect  over  a  weak  and  irritable  heart  is  often  observed  in  less 
than  an  hour.  It  does  not  control  irregularity  of  action,  as  well 
as  abnormal  rapidity.  Hence  it  is  the  remedy  for  tachycardia 
in  children.  The  other  conditions  in  which  it  is  useful  are 
pulmonary  emphysema  with  chronic  myocarditis  and  irritable 
heart  ;  insufiticiency  of  the  aortic  valves  ;  valvular  disease  with 
failing  compensation ;  weak,  rapid  action  of  the  heart  in 
Bright's  disease,  with  deficient  action  of  the  kidneys,  dropsy, 
ascites,  etc. 

In  threatened  heart  failure  during  scarlatina  with  endocar- 
ditis, one-tenth  of  a  grain  of  spartein  hypodermatically  will  act 
in  fifteen  minutes,  and  will  thus  sustain  the  temporary  stimula- 
tion of  amyl  or  glonoin.  As  a  heart  tonic  and  sedative  use 
the  2x  trituration  in  young  infants,  the  ix  in  older  children, 
repeating  the  dose  every  two  hours. 

Spigelia. — The  symptoms  indicating  this  drug  are  too  well 
known  to  be  recorded  here.  When  called  for  by  those  symp- 
toms it  is  of  inestimable  value  in  acute  peri-  and  endocarditis ; 
the  painful  and  stormy  palpitations  of  all  acute  and  chronic 
cardiac  maladies  ;  but  especially  in  violent  cases  of  persistent 
tachycardia,  exophthalmus,  and  chorea  of  the  heart. 


416  THE  DISEASES  OF  CHILDREN. 

Many  functional  disturbances  of  the  heart  are  due  to  the  re- 
ilex  irritation  set  up  by  worms  in  the  stomach  and  intestines. 
Here  spigelia  has  a  happy  effect  in  quieting  such  disturbances, 
but  in  order  to  prevent  their  recurrence  the  parasites  should  be 
expelled. 

Squilla. — At  the  time  the  original  proving  of  squilla  was 
made,  no  method  of  testing  its  effects  upon  the  heart  was  in 
use.  But  if  a  careful  study  of  these  provings  be  made,  it  will  be 
seen  how  closely  its  chest  and  respiratory  symptoms  compare 
with  the  bronchial  and  pleuritic  troubles  which  are  so  often 
present  in  mitral  lesions.  Owing  to  the  imperfect  supply  of 
blood  to  the  lungs  in  the  mitral  disease,  the  lungs  and  espe- 
cially the  bronchial  mucous  membrane  becomes  congested  this 
causes  a  profuse  flow  of  mucus  (bronchorrhea)  or  acute  bron- 
chitis, also  edema  and  venous  stasis  of  the  lungs,  and  even 
pleuritic  effusion.  The  cough  in  such  cases  closely  resembles 
the  cough  of  squilla,  namely  loose,  rattling,  constantly  harass- 
ing day  and  night,  sometimes  loose,  then  dry,  spasmodic,  dis- 
turbing sleep  ;  loose  in  the  morning,  dry  in  the  evening.  The 
expectoration  is  either  glairy  or  bloody  and  is  very  diflficult  to 
raise,  although  a  large  quantity  seems  to  be  in  the  chest.  The 
allopathic  abuse  of  this  drug  is  fearful.  They  give  it  to  "loosen 
the  cough."  They  do  not  know  that  the  bronchorrhea  which 
they  cause  is  due  to  the  congestion  of  the  lungs  and  bronchial 
mucous  membrane,  depending  on  cardiac  weakness  and  irregu- 
lar action,  and  that  many  of  the  cases  of  so-called  bronchitis 
and  pneumonia  in  children  are  made  worse  by  the  toxic  action 
of  squilla.  If  the  patients  did  not  vomit  up  most  of  the  drug 
the  mortality  would  be  greater.  The  pathogenetic  action  of 
squilla  is  not  unlike  convallaria — (all  the  liliaceae,  in  large 
doses,  are  more  or  less  cardiac  poisons).  The  primary  effect  of 
large  doses  of  squilla  is  to  cause  increased  force  and  more  rapid 
contractions  of  the  ventricles  ,  the  pulse  is  small  and  hard,  wiry, 
then  becomes  irregular  and  very  rapid,  and  finally  ceases  from 
tonic  closure  of  the  ventricles.  During  this  time  the  pulmonary 
circulation  is  rendered  imperfect,  and  there  is  present  passive 
congestion.  Hence  the  cough,  mucus  rales,  bloody  sputa, 
dyspnea,  pleuritic  pains,  profuse  urine,  etc.  It  is  my  conviction 
that  nearly  all  the  symptoms  of  the  chest  and  urinary  organs 
caused  by  squilla  are  produced  by  the  action  of  this  drug  on 
the  heart,  and,  except  in  some  cases  of  influenza,  it  is  only  in- 
dicated in  chest  affections  when  cardiac  disorder  is  present. 
Many  of  the  cases  diagnosticated  as  bronchitis,  pneumonia  and 
pleurisy  in  children  are  probably  due  to  acute  endocarditis, 
pericarditis,  or  chronic  valvular  diseases,  which  we  now  know 
are  very  common  in  early  life.     In  acute  cases,  presenting  the 


INDICATIONS  FOR  MEDICINES.  417 

characteristic  symptoms  of  squilla,  it  should  be  given  in  minute 
doses  (third  dilution),  or  the  malady  will  be  dangerously  aggra- 
vated. 

Per  contra,  in  cases  of  cough,  dyspnea,  bronchorrhea  and 
pleuritic  affections  of  a  neglected  or  chronic  nature,  when  the 
symptoms  often  assume  the  character  of  the  secondary  symp- 
toms of  squilla,  namely,  constant  hawking,  loose  or  dry  cough, 
great  oppression  of  breathing,  aggravated  by  movement  and 
lying  down,  the  face  pale  and  cold,  hands  and  feet  cold  and  blue, 
heart's  action  feeble,  irregular,  palpitating,  but  always  deficient 
in  force,  urine  scanty,  red,  painful  and  often  bloody,  this  rem- 
edy will  be  found  promptly  curative  in  larger  but  not  patho- 
genetic doses.  I  have  found  the  first  dilution,  in  doses  of  five 
drops  every  hour  or  two,  or  the  first  trituration,  in  grain  doses, 
act  with  the  happiest  curative  effect.  In  dropsy  from  valvular 
disease  it  should  not  be  used  empirically,  but  always  selected 
by  the  totality  of  its  symptoms. 

Sterculia  (Kola).  —  Kola,  by  the  caffein  and  theobromin 
which  it  contains,  is  a  tonic  of  the  heart,  whose  pulsations  it 
accelerates,  while  it  increases  its  power  and  regulates  its  con- 
tractions. In  the  second  phase  of  its  action  it  becomes,  like 
digitalis,  a  regulator  to  the  pulse,  whose  energy  it  raises  ;  under 
its  influence  the  pulsations  become  more  ample  and  less  nu- 
merous. As  a  result  of  its  effect  on  the  vascular  tension,  diu- 
resis augments,  and  this  fact  renders  it  valuable  in  affections  of 
the  heart  with  dropsy.  It  is  a  waste  restrainer,  diminishing 
the  losses  of  the  economy  from  the  combustion  of  the  azotized 
compounds,  probably  from  special  action  on  the  nervous  sys- 
tem. It  is  a  powerful  tonic  by  the  principles  which  it  contains, 
and  its  employment  is  indicated  in  anemias,  in  chronic  affec- 
tions of  debilitating  character,  and  in  convalescence  from  grave 
fevers.  It  favors  digestion,  probably  by  augmenting  the  secre- 
tion of  gastric  juice,  and  by  acting  on  the  unstriped  muscles  of 
the  stomach,  which  it  tonifies.  Under  its  influence  anorexia 
disappears,  and  the  digestive  functions  become  more  regular. 

Kola  increases  the  assimilation  of  food,  and  in  cases  of  weak 
heart  with  chronic  intestinal  catarrh  in  children,  will  form  an 
invaluable  remedy. 

Lastly,  it  is  an  anti-diarrheic  medicament  of  great  value,  and 
as  such  has  rendered  good  service  in  chronic  diarrhea,  and  in 
certain  cases  of  sporadic  cholera,  although  its  action  in  these 
instances  may  not  as  yet  be  clearly  explained.  The  mother- 
tincture  may  be  used  in  doses  of  five  to  thirty  drops.  It  can 
be  given  pleasantly  in  sweetened  milk.  Infants  and  children 
will  take  this  without  objection. 

Stigmata  Maidis  (Corn  silk). — This  apparently  simple  drug 
D.  C— 27 


418  THE  DISEASES  OF  CHILDREN. 

is  of  great  value  in  some  of  the  milder  cases  of  chronic  valvular 
disease  with  deficient  compensation.  The  symptoms  indicating 
it  are  :  weak  action  of  the  heart,  with  irregular,  intermittent 
pulse,  deficient  quantity  of  urine  with  frequent  and  urgent  de- 
sire to  urinate,  only  a  small  quantity  being  passed.  Edema 
of  the  lower  Hmbs  and  even  general  dropsy.  Under  the  use  of 
five  to  ten  drops  of  the  tincture  every  three  hours,  the  urine 
will  increase  in  quantity,  and  the  irritability  of  the  bladder  de- 
crease, while  the  dropsy  and  weak,  irregular  action  of  the  heart 
will  disappear. 

Strophanthus. — This  remedy  has  attained  a  good  reputation 
as  a  substitute  for  digitalis.  It  is  not  open  to  many  of  the  ob- 
jections against  the  latter.  It  does  not  contract  the  arteries  to 
the  same  extent ;  or  derange  the  stomach,  or  show  any  of  the 
so-called  "cumulative  action."  It  is  also  el^cient  in  smaller 
doses.  This  refers  to  its  physiological  action.  Of  its  strict 
homeopathic  uses  we  know  but  little,  as  we  have  no  provings. 
There  is  one  group  of  symptoms,  however,  which  it  has  caused 
when  given  in  too  large  doses.  They  are  complete  anorexia,  dis- 
gust for  all  food,  gagging  and  choking  from  regurgitation  and 
vomiting  of  food  soon  after  eating,  with  severe  diarrhea.  These 
symptoms  sometimes  occur  during  acute  endocarditis,  and  then 
the  3x  dilution  will  soon  remove  them.  The  following  are  the 
conditions  it  has  removed :  "  In  valvular  weakness  in  the  stage 
of  compensation  disturbance,  tincture  of  strophanthus  will  re- 
tard, strengthen  and  regulate  the  cardiac  action.  The  retarda- 
tion occurs  first,  while  the  regulating  effect  only  takes  place  as 
a  rule,  after  a  few  days.  Dyspnea  and  edema  are  promptly 
relieved.  But  the  favorable  effects,  in  about  one-half  the  cases, 
do  not  appear  with  the  regularity  and  safety  peculiar  to  digi- 
talis ;  and  in  most  cases  in  which  strophanthus  failed,  digitalis 
was  effective.  Digitalis  has,  generally,  a  quicker  and  more 
thorough  effect,  especially  in  causing  diuresis,  while  strophan- 
thus affects  a  disturbed  respiration  far  more  favorably.  It  is 
more  difficult  to  indicate  strophanthus  than  digitalis  in  cases  of 
valvular  weakness,  so  that  it  is  almost  impossible  to  say  before- 
hand in  what  case  strophanthus  will  be  successful. 

In  chronic  degeneration  of  the  cardiac  muscle,  with  usually 
a  small,  frequent  and  irregular  pulse,  great  difificulty  in  breath- 
ing and  edemas,  tincture  of  strophanthus  may  be  relied  upon. 

In  acute  and  chronic  nephritis  the  effect  of  strophanthus  is 
not  so  marked  as  in  the  above  mentioned  affections.  The  dysp- 
nea often  yields  to  its  influence  as  in  the  other  diseases,  but 
the  diuresis  and  edemas  are  not  favorably  affected  by  it. 

It  cases  of  palpitation  and  apnea  of  nervous  origin,  strophan- 
thus often  gives  marked  relief. 


INDICA  TIONS  FOR  MEDICINES.  419 

Edemas  of  cachectic  character  may  be  also  favorably  affected 
by  it.  For  children,  begin  with  doses  of  gtts.  vij.  of  the  ix  in 
a  teaspoonful  of  water  or  wine,  and  add  gtts.  ij.  to  each  dose 
until  the  effect  is  obtained,  though  it  is  not  advisable  to  give 
more  than  gtts.  xx  every  three  hours. 

The  effect  usually  appears  on  the  second  or  third  day,  and 
generally  lasts  a  week  or  two  weeks,  though  there  is  considera- 
ble variation. 

Zinc  cyanide. — This  drug  is  of  great  value  in  angina  pectoris, 
and  those  reflex  affections  of  the  heart  in  children,  which  arise 
from  irritation  of  the  brain  or  stomach.  The  symptoms  are 
sudden,  violent  pain  in  the  region  of  the  heart,  with  pale  face, 
dusky  lips,  tossing  about  in  anxiety,  irregular,  feeble  pulse, 
vomiting,  and  sometimes  stupor  and  convulsions. 


PA  RX     VIM. 

DISORDERS  OF   THE  URINARY  TRACT 


CHAPTER    I. 

THE  URINE  OF  INFANCY  AND  CHILDHOOD. 

Quantity  of  Urine  in  2if.  Hours. — During  the  first  ten  days  of 
life  the  infant  passes,  according  to  Cruse,  from  130  c.  c.  to  417 
c.  c.  (4  to  14  ounces).  The  quantity  increases  rapidly  during 
the  first  ten  days,  but  more  slowly  during  the  next  week.  At 
the  end  of  the  first  month  the  average  is  from  about  200  c.  c.  to 
300  c.  c.  (6  to  10  fluidounces).  During  the  first  year,  the  aver- 
age is  from  300  c.  c.  to  400  c.  c.  (10  to  13  fluidounces). 

During  infancy  the  child  passes  about  one  fluidounce  (30  c.  c.) 
for  each  pound  (half-  kilogram)  of  weight :  this  figure  applies 
especially  to  children  between  three  and  seven  years  of  age. 

The  following  table  shows  the  figures  of  different  observers 
in  regard  to  the  quantity  of  urine  in  24  hours : 


ULTZMANN. 

Infancy 300  c.  c.  (10  fl.  oz.) 

Increasing  100  c.  c.  (3  fl.  oz.)  for 
each  year  until  the  15th,  when 
the  normal  quantity  is  1500  c.  c. 
(50  fl.  oz.). 

Boys  of  8..  .  . 
Girls  of  8.... 
Boys  of  10.. . 
Girls  of  10..  . 
Boys  of  12..  . 
Girls  of  12..  . 

HERZ. 

.  .700  c.  c.  (23  fl.  oz.) 

.  .600  c.  c.  (20  fl.  oz.) 
. .  .750  c.  c.  (25  fl.  oz.) 

.  .700  c.  c.  (23  fl.  oz.) 
.  .1000  c.  c.  (33  fl.  oz.) 

.  .800  c.  c.  (26  fl.  oz.) 

SCHABANOWA. 

2  to    4  years.  ..500  c.  c.  (16  fl.  oz.) 

5  to    9  years. .  1000  c.  c.  (33  fl.  oz.) 

lo  to  13  years..  1500  c.  c.  (50  fl.  oz.) 

CHARLES. 

3  to  5  (boys)  .  .  .750  c.  c.  (25  fl.  oz.) 
3  to  5  (girls)  .  .  .700  c.  c.  (23  fl.  oz.) 

In  regard  to  the  24  hours'  urine  of  the  healthy  new-born, 
Parrot  and  Robin  think   150  to  300  c.  c.  (5  to  10  fl.  oz.)  the 
average  from  the  6th  to  the  30th  day  ;  in  other  words,  a  new- 
born child  passes  four  or  five  times  more  urine  per  kilogram  of 
(420) 


THE   URINE  OF  INFANCY.  421 

weight  than  an  adult.     Their  observations  on  the  quantity  of 
morning  urine  voided  were  as  follows : 

1st  to      5th  day,  morning  emission 5  to  10  c.  c. 

5th  to    loth     "  "  "        10  to  25  c.  c. 

loth  to    15th     "  "  •'        15  to  30  c.  c. 

15th  to    30th     "  "  "       20  to  30  c.  c. 

30th  to  150th     "  "  "       2510350.0. 

Clinical  Note. — If  then  the  urine  diminishes  notably  it  is 
because  the  child  is  sick  or  is  fed  in  an  insuflficient  manner. 

Collecting  the  Urine  of  Infants. — In  order  to  collect  the  urine 
of  young  children,  place  a  clean  sponge  over  the  genitals  and 
fasten  the  diaper  over  it.  The  sponge,  when  saturated,  is  re- 
moved, squeezed  out  over  a  lipped  dish,  and  the  urine  poured 
from  the  dish  into  a  bottle  or  glass  for  measurement  and 
examination. 

Color. — The  normal  urine  of  young  children  has  little  color, 
light  yellow  at  most.  If  the  first  act  of  micturition  be  delayed 
twenty-four  hours,  the  color  of  the  urine  will  be  dark,  from 
concentration  in  the  bladder. 

In  two-thirds  of  the  cases  mentioned  by  Parrot  and  Robin,* 
the  urine  of  the  new-born  was  absolutely  watery ;  in  the  others 
very  slightly  tinged,  of  great  refractive  power,  and  of  very 
light,  straw-color,  like  that  of  old  Chablis;  more  rarely  green 
reflections  were  noticed,  especially  when  seen  by  transmitted 
light ;  after  standing  some  hours  exposed  to  the  air,  the  color 
deepened  a  little.  During  the  first  days  of  life,  when  the  new- 
born child  loses  something  of  its  initial  weight,  the  urine  is 
often  more  highly  colored — rather  yellow  like  that  of  the  adult. 
The  color  may  be  further  modified  by  the  weight  of  the  child 
and  its  alimentation;  thus,  it  is  darker  with  heavy  children,  and 
paler  with  those  nursed  by  their  mother  than  those  who  are 
brought  up  on  the  bottle  or  otherwise  nursed. 

Temperature. — The  temperature  of  the  urine  of  the  healthy 
new-born  child  varies  only  in  a  very  small  range,  from  98.2° 
to  99.3°. 

Odor. — The  urine  of  children  has,  in  health,  less  odor  than 
that  of  adults.  After  standing  for  a  time,  the  odor  somewhat 
suggests  that  of  veal  broth.  Colorless  urine  is  usually  inodor- 
ous; that  which  has  more  color  has  a  feeble,  urinous  odor, 
which  boiling  does  not  sensibly  develop. 

Specific  Gravity. —  Contradictory  statements  are  found  in 
regard  to  the  specific  gravity.  At  birth  the  specific  gravity  is 
said  by  some  to  be  about  loio;  it  then  sinks  as  low  sometimes 


G.  E.  Shipman^s  Translation,  Chicago,  i{ 


422  THE  DISEASES  OF  CHILDREN. 

as  to  I002,  by  the  tenth  day,  gradually  rising  again.  At  the 
age  of  a  month  it  may  be  as  low  as  10x33.  In  general,  during 
infancy,  it  varies  from  1003  to  1006,  though  Schabanowa  places 
the  figures  at  ion  between  two  and  four,  1013  from  five  to 
nine,  and  1012  from  ten  to  thirteen. 

Cruse  says  that  the  specific  gravity  increases  rapidly  from 
the  fifth  to  the  tenth  day,  then  diminishes ;  that  the  average 
specific  gravity  is  from  1005  to  loio. 

According  to  Parrot  and  Robin,  with  children  from  five  to 
thirty  days  old,  the  mean  density  of  the  urine  varies  from  1003  to 
ICX)4.  The  product  of  the  first  urination  is  denser  and  attains 
the  figures  ICXD5  and  1006.  From  one  to  four  months  the  den- 
sity is  1004  ^nd  1005.  According  to  Quinquand,  the  density 
at  birth  is  1003;  about  the  loth  or  15th  day,  1006. 

Reaction. — In  the  new-born  the  urine  is  normally  neutral  in 
reaction,  only  exceptionally  being  feebly  acid.  If  the  first 
micturition  is  delayed  twenty-four  hours,  the  urine  may  be 
acid  from  concentration  in  the  bladder. 

Clinical  Note. — Acid  urine  in  the  new-born  is  indicative  of 
something  wrong  in  the  regimen  as,  for  example,  too  long  an 
interval  between  the  nursings. 

Appearance. — For  the  first  four  or  five  days  after  birth  the 
urine  of  children  is  rather  turbid,  owing  to  presence  of 
epithelia,  mucus,  urates,  and  occasionally  calcium  oxalate. 
Later  it  becomes  clear  with  the  usual  faint  mucous  cloud. 
The  consistence  is  watery  and  the  frothiness  not  permanent  in 
health. 

The  first  act  of  micturition  may  be  delayed  twenty-four 
hours,  in  which  case  the  urine  will  be  turbid  and  concentrated 
by  absorption  in  the  bladder.  But  if  the  urine  be  passed  soon 
after  birth,  it  will  be  clear  and  pale. 

The  urine  of  new-born  children  is  light-colored,  thin,  limpid 
and  of  great  mobility  ;  to  this  rule,  according  to  Parrot  and 
Robin,  there  are  three  exceptions.  First,  urines  opalescent  at 
the  moment  of  expulsion,  but  which,  after  standing  some  hours, 
become  limpid  again,  depositing  at  the  bottom  of  the  vessel 
very  delicate  and  scanty  flocks,  made  up  of  the  epithelium  of  the 
urinary  passages  and  of  the  vulva  in  case  of  female  children  ; 
second,  urines  light  when  passed  and  bleaching  in  from  two  to 
four  hours,  then  becoming  limpid  again  on  deposit  of  the  sus- 
pended matters  causing  the  turbidity ;  these  latter  are  bright 
crystals  of  uric  acid  formed  at  the  moment  when  urine,  neutral 
at  first,  has  undergone  acid  fermentation.  These  two  varieties 
of  opalescence,  observed  especially  during  the  first  two  or  three 
days  of  life,  are  almost  constant  in  children  prematurely  born. 
In  the  third  case  we  find  urines  turbid  when  exposed  to  the 


UREA. 


423 


air  for  twenty-four  hours  or  more,  from  development  of  micro- 
organisms. 

Clinical  Note. — In  the  great  majority  of  cases,  limpid,  thin, 
colorless,  inodorous  urine  of  low  specific  gravity  is  found  only 
among  healthy  new-born  children. 

Urea. — The  amount  of  urea  in  24  hours  is  best  reckoned  in 
grains  per  pound  of  body-weight,  or  grams  per  kilogram. 
The  new-born  infant  up  to  one  month  of  age  voids  about  one 
and  three-quarters  grains  of  urea  for  each  pound  of  body-weight, 
or  0.23  gram  per  kilogram.  The  following  tables  show  the 
figures  of  the  different  authorities: 


CAMERER. 

Children  void  5  to  8^^  grains  for 
each  pound   of   weight   (0.64  to 
1. 12  grams  per  kilogram). 

HARLEY. 

Boy  of  18  months — 
6.2  grains  per  pound. 
0.4  grams  per  pound. 
124  to  186  grains  in  24  hours. 
8  to  12  grams  in  24  hours. 

Girl  of  18  months — 
5.4  grains  per  pound. 
0.35  grams  per  pound. 
93  to  140  grains  in  24  hours. 
6  to  9  grams  in  24  hours. 

RALFE. 

4/^   grains    to    the    pound    for    a 

weight  of  40  to  60  pounds. 
4  grains  to  the  pound  for  a  weight 

of  60  to  120  pounds. 
Child    of   five    of   40   pounds,    iSo 

grains  in  24  hours. 
Child  of  twelve  of  80  pounds,  320 

grains  in  24  hours. 

UHLE. 

3  to  6  years — 7)^  grains  per  pound, 

I  gram  per  kilogram. 
8  to  II  years — 6  grains  per  pound, 

0.8  grams  per  kilogram. 
13  to  1 6  years — 3  to  4%  grains  per 

pound,    0.4    to    0.6    grams    per 

kilogram. 

HAIG. 

Child    3   or   4  years    old,   9  or    10 
grains  per  pound. 

The  analyses  of  Parrot  and  Robin  showed  that  urine  con- 
tained, as  a  mean,  3.03  grams  per  liter  of  urea  in  children  from 
a  day  to  a  month  old,  of  an  average  weight  of  3850  grams  ; 
hence,  it  results  that  every  liter  of  such  urine  contains,  per 
kilogram  of  child's  weight,  0.80  gram  of  urea.  A  new-born 
child,  which  in  twenty-four  hours  passes  300  grams  of  urine 
will  then  void  0.96  gram  of  urea,  or  0.25  gram  per  kilogram 
of  weight.  But  the  age,  weight,  and  bodily  temperature 
modify  in  a  very  marked  degree  the  quantity  of  urea.  A 
new-born  child  passes  more  urea  per  liter  and  per  kilogram 
of  its  weight  on  the  first  day  of  its  life  than  on  the  twentieth, 
when  the  estimation  per  kilogram  of  weight  is  based  on  the 
urea  per  liter:  but  if  the  estimation  per  kilogram  of  weight 


424 


THE  DISEASES  OF  CHILDREN. 


is  based  on  the  urea  per  twenty-four  hours,  it  will  be  found, 
according  to  Parrot  and  Robin,  that  inasmuch  as  the  twenty-four 
hours  urine  increases  with  age,  the  twenty-four  hours  urea  in- 
creases also,  and  the  urea  per  kilogram  of  weight  also  increases. 
The  tables  quoted  by  Parrot  and  Robin  are  as  follows : 


PER   LITER. 


Age. 

Mean  weight 
of  child. 

Urea  per 
liter  of  urine. 

Urea  per 

kilogram 

of  child's 

weight. 

Number  of 
experiments. 

First  day 

Grams. 
3725 
3331 
4117 
3760 

3559 
3937 
3560 
4918 

Grams. 

7  05 
4.67 

4.38 
2.10 
1.70 
2.39 
2-73 
2.98 

0-55 
0.47 
0.60 
0.76 
0.63 

3 

Second  day 

C 

Third  day 

3 

Fourth  day 

^th  to  9th  day 

3 

Tenth  day 

4 
16 

18 

nth  to  30th  day 

30th  to  150th  day 

PER   24   HOURS. 


Agk. 


Quantity 

of  urine  \n  24 

hours. 


Quantity 

of  urea  in  24 

hours. 


Urea  per 
kilogram 
of  child. 


First  day 

Second  day 

Third  day 

Fourth   day 

5th  to  9th  day . . . 

Tenth  day 

nth  to  30th  day. 
30th  to  150th  day 


Grams. 

15 

30 

60 

100 

150 
209 
300 
350 


Grams. 
0.10 

o.  14 

0.26 
0.21 
0.25 
0.47 
0.81 
I  .04 


Grams. 
0.03 
0.04 
0.06 
0.05 
0.07 
0.12 
0.23 
0.23 


The  apparent  contradiction  as  regards  urea  per  kilogram 
of  child's  weight  is  readily  explained  by  considering  the  fact 
that  the  urea  is  reckoned  differently  in  the  two  tables — in  the 
first  one  relatively  or  physiologically,  and  in  the  second  abso- 
lutely or  clinically. 

A  heavy  child  is  said  to  pass  less  urea  per  kilogram  of 
body  weight  than  one  of  less  weight,  but  more  per  liter  of  urine. 

According  to  Parrot  and  Robin,  the  more  easily  a  new-born 
child  is  chilled  the  more  urea  per  liter  does  the  urine  contain. 

The  quantity  of  urea  is  constantly  diminished  in  the  ne- 
phritis of  children.   It  is  also  diminished  in  anemia  and  chlorosis. 


UREA.  425 

Chlorine. — Children  above  three  years  of  age  void,  according 
to  Charles,  4.5  to  5.3  grams  of  chlorin,  corresponding  to 
71-2  to  8  3-4  grams  of  chlorides  (116  to  136  grains),  in  the 
twenty-four  hours. 

According  to  Parrot  and  Robin,  in  children  from  three  to 
thirty  days  old,  the  general  mean  of  chlorides  was  0.79  gram  per 
liter,  or  0.22  per  kilogram  of  body-weight.  The  chlorides 
estimated  per  liter  of  urine  increased  progressively  from  birth 
to  the  thirtieth  day. 

In  the  urine  of  the  new-born  Parrot  and  Robin,  in  fifteen  cases, 
always  found  chlorides,  but  sometimes  in  such  small  proportion 
that  to  determine  them  exactly  was  impossible. 

Sulphuric  Acid. — The  urine  of  the  new-born  contains  sul- 
phates, but,  according  to  Parrot  and  Robin,  in  too  slight  propor- 
tions to  allow  determination  of  them  by  weight.  Accurate 
analyses  of  the  sulphates  in  the  urine  of  children  are  difficult 
to  obtain.  The  works  thus  far  consulted  by  the  writer  throw 
little  or  no  light  on  the  subject,  except  that  the  substances 
have  been  found  to  be  diminished  in  cases  of  nephritis  in 
children. 

Phosphoric  Acid. — In  the  first  eight  days  after  birth,  children 
excrete  0.014  to  0.032  per  cent,  phosphoric  acid  as  compared 
with  0.19  to  0.23  per  cent,  in  the  adult.  In  young  infants,  the 
amount  of  earthy  phosphates  is  very  small.  The  proportion  is 
much  less  in  growing  children  than  in  adults. 

According  to  Cruse,  the  phosphoric  acid  increases  after  the 
tenth  day. 

Von  Jaksch,  differing  from  other  observers,  has  found  that 
in  some,  though  not  all,  cases  of  lobar  pneumonia  among 
children,  the  quantity  of  phosphoric  acid  eliminated  during  the 
continuance  of  fever  was  increased,  as  compared  with  the  non- 
febrile  period.  He  also  finds  phosphoric  acid  diminished  in  the 
urine  of  children  suffering  from  nephritis. 

According  to  Parrot  and  Robin,  a  new-born  child  passes  per 
liter  more  phosphoric  acid  from  the  sixteenth  to  the  thirtieth 
day  than  from  the  first  to  the  fifteenth,  and  the  maximal  quan- 
tity which  the  urine  may  contain  during  that  period  in  the 
case  of  health  is  1.95  gram  per  liter  or  0.47  gram  per  kilogram 
of  body-weight. 

Uric  Acid. — In  the  new-born  the  quantity  of  uric  acid  is  pro- 
portionally greater  than  in  the  adult,  forming  0.13  per  cent, 
during  the  first  week,  then  decreasing  up  to  0.04,  an  adult 
secreting  about  0.03  to  0.05  per  cent.  The  ratio  of  urea  to  uric 
acic  in  the  new-born,  according  to  Mares,  is  about  1:13-14. 

Ranke  claims  that  neither  age  nor  sex  have  any  effect  on  the 
excretion  of  uric  acid. 


426 


THE  DISEASES  OF  CHILDREN. 


Saundly  says  the  urine  of  the  new-born  contains  much  uric 
acid, 

Haig  affirms  that,  in  a  child  of  three  or  four  years,  uric  acid 
per  twenty-four  hours  may  amount  to  as  much  as  0.27  to  0.30 
grains  per  pound  of  body-weight. 

Von  Jaksch  finds  uric  acid  diminished  in  the  urine  of  children 
suffering  from  nephritis. 

Creatinin. — Infants  on  pure  milk  diet  excrete  little  or  no 
creatinin.  Grocco  finds  very  small  quantities  in  the  urine  of 
babes  on  an  exclusive  milk  diet.  Boys  ten  to  twelve  years  old 
excrete  a  mean  of  0.387  gram  (6  grains)  in  the  twenty-four 
hours. 

Meat  diet  considerably  increases  the  creatinin  even  in  young 
children. 

Indican. — According  to  Hochsinger,  indican  is  absent  from 
the  urine  of  the  new-born  and  at  best  is  only  found  in  traces 
during  the  entire  period  of  infancy ;  but  is  increased  in  gastro- 
enteritis and  in  cholera  infantum.  Excluding  primary  intes- 
tinal or  general  septic  diseases,  the  presence  of  pathological 
quantities  of  indican  is  indicative  of  grave  intestinal  disturbance 
or  grave  general  functional  change,  especially  tuberculosis. 
Smith  has  found  amorphous  masses  of  indigo-blue  in  the  urine 
of  a  child  affected  with  digestive  disturbance.  At  least  once 
these  amorphous  masses  were  replaced  by  minute  rhombic 
crystals  of  a  blue  color. 

Urobilin. — A  deep-brown  zone  of  color,  seen  when  Heller's 
cold  nitric  acid  test,  for  albumen,  is  applied,  and  growing 
lighter  as  it  recedes  from  the  acid,  is  noticed  in  some  cases  of 
cirrhosis  of  the  liver,  and  is  regarded  as  an  unfavorable  sign. 
The  same  reaction  is  said  to  occur  in  cancer,  lead-poisoning, 
alcoholic  poisoning,  rheumatism,  gout,  pneumonia,  angina,  and 
intermittent  fever.  It  is  considered  by  Hayene,  a  proof  of 
hepatic  incompetency,  due  to  a  languid  liver  manufacturing 
urobilin  instead  of  normal  bile-pigments. 

Albumin. — Albumin  may  be  found  in  the  urine  of  children 
under  the  following  circumstances : 


1.  Without  known  cause,  so-called 
**  functional"  albuminuria. 

2.  In  febrile  states. 

3.  Due  to  presence  of  pus,  blood, 
or  chyle  in  the  urine  or  found  ac- 
companying bile. 


4.  From    pressure   on  renal  veins 
by  tumors,  etc. 

5.  In  nephritis. 

6.  In  convulsions,  epilepsy,  etc. 

7.  In  poisoning. 


I.   FUNCTIONAL  ALBUMINURIA. 


Functional  albuminuria  is  more  common   in  boys  than  in 
girls.     The  quantity  of  albumin  may  be  very  small  or  quite 


ALBUMIN.  427 

large — as  high  as  half  by  bulk.  It  is  usually  absent  in  the 
morning  and  present  after  food  or  exercise.  No  casts  can  be 
found,  even  after  most  careful  search. 

Albumin  is  found  in  the  urine  of  infants  before  the  urinary 
secretion  has  begun,  and  in  that  of  weak  and  delicate  children 
at  puberty. 

In  regard  to  the  prevalence  of  this  form  of  albuminuria  in 
children,  the  following  may  be  of  interest : 

It  was  found  in  38  out  of  97  children  examined  by  Capitan, 
in  quantities  varying  from  0.007  ^^  0.02  gram  per  liter 
(0.0032  to  0.009  grain  per  ounce).  Stewart  found  albumin  in 
the  urine  of  17  out  100  healthy  children.  Stirling  found  albu- 
min in  "jy  out  of  369  healthy  boys.  Leroux  found  albuminuria  in 
5  percent,  of  330  presumably  healthy  children.  Fiirbringer  found 
it  in  11^  per  cent,  of  61  children.  Janeway  frequently  finds 
albumin  in  the  urine  of  debilitated  children.  De  la  Celle  found 
albuminuria  in  'j6  to  80  per.  cent,  of  presumably  healthy  chil- 
dren from  six  to  fifteen  years  of  age,  in  quantities  from  5  to  9 
centigrams  per  liter. 

2.   ALBUMINURIA  IN  FEBRILE  STATES. 

Albuminuria  of  brief  duration,  and  rarely  of  prognostic  signif- 
icance, is  quite  commonly  found  in  the  urine  of  measles,  diph- 
theria and  scarlet  fever.  Binet  found  albuminuria  in  all  of  27 
cases  of  pneumonia  and  broncho-pneumonia  in  children ;  Eckert 
found  it  very  common  in  cases  of  typhus  and  typhoid  fever, 
occurring  in  three-fourths  of  all  children  he  examined,  appear- 
ing most  commonly  in  the  first  week,  or  even  the  first  days  of 
the  affection,  and  lasting  usually  about  one,  or  one  and  a  half 
weeks,  the  quantity  of  albumin  having  close  relation  to  the  in- 
tensity of  the  attack. 

Sejournet  found  albuminuria  in  children  from  fault  of  diet, 
the  result  of  abnormal  intestinal  fermentations,  and  due  to  con- 
gestion of  the  kidneys.  Such  albuminuria  evinced  to  some 
degree  an  infectious  nature. 

3.  ALBUMIN  IN  THE  URINE  DUE  TO  PRESENCE  OF  PUS, 
BLOOD,  OR  CHYLE. 

Urine  of  children  containing  pus  will  show  albumin  when 
the  tests  are  applied.  Pus  in  the  urine  may  be  due  to  gonor- 
rhea, which  may  be  found  in  female  children  as  the  result  of 
rape  or  inoculation  from  parents  ;  leucorrhea,  which  sometimes 
occurs  in  girls  as  young  as  three  ;  cystitis  (most  commonly  in 
children  due  to  stone);  pyelitis,  suppurative  nephritis,  malig- 
nant disease,  and  tuberculosis.     (See  Pyuria.) 


428  THE  DISEASES  OF  CHILDREN. 

Urine  of  children  containing  blood  will  contain  albumin  also. 
(See  Hematuria  and  Hemoglobinuria.) 

When  chyle  is  found  in  the  urine,  albumin  also  occurs.  (See 
Chyle.) 

4.   ALBUMIN   IN   THE   URINE   DUE   TO   PRESSURE   ON 
RENAL    VEINS. 

The  tumors  which  by  pressure  on  the  renal  veins  cause 
albuminuria  are,  in  the  main,  those  of  carcinomatous  nature ; 
sarcoma  of  the  kidney  has  been  noticed  in  children,  also  fib- 
roma and  rhabdomyoma.  Tyson  includes  under  this  heading 
pressure  from  hydatid  cysts.     (See  Cancer  of  the  Kidney.) 

5.   ALBUMINURIA   IN   NEPHRITIS. 

When  albumin  is  found  in  the  urine,  together  with  casts  and 
renal  epithelium,  the  question  is  one  which  will  be  discussed 
under  the  head  of  nephritis,  q.  v. 

6.  ALBUMINURIA  IN   EPILEPSY. 

Albumin  has  been  found  by  Huppert  in  the  urine  after  full- 
formed  epileptic  seizures  for  from  three  to  four  hours.  Other 
observers  have  failed  to  find  it  ;  Mabille,  for  instance,  in  38 
cases,  failed  to  find  any  either  before,  during,  or  after  the  seizure. 

7.   ALBUMINURIA   IN   POISONING. 

Albuminuria  is  common  in  children  who  are  taking  arsenic 
in  large  doses,  as  in  the  treatment  of  chorea. 

Peptone. — Binet  found  peptone  in  the  urine  of  34  infant 
patients  out  of  248.  It  occurs  most  frequently  in  diphtheria 
and  in  acute  and  chronic  nephritis.  He  does  not  regard  the 
symptom  as  of  much  value  as  a  diagnostic  and  prognostic 
factor.  Peptonuria  is  said  to  occur  in  some  cases  of  diabetes 
insipidus. 

Arslan,  of  Paris,  as  a  result  of  experiments  performed  in  the 
scarlatina  wards  of  the  Sick  Children's  Polyclinic,  draws  the 
following  conclusions : 

1.  No  peptone  is  found  in  the  urine  in  mild  cases  of  simple 
scarlatina. 

2.  The  urine  contains  peptone  in  grave  cases  of  the  disease 
associated  with  complications — the  occurrence  of  the  latter 
being  even  frequently  preceded  by  peptonuria. 


ALBUMINURIA  IN  POISONING.  429 

3.  The  presence  of  a  considerable  quantity  of  peptone  in  the 
urine  is  an  unfavorable  sign. 

4.  The  peptonuria  is  in  no  way  influenced  by  the  presence 
of  albumin,  the  condition  of  the  pulse,  or  the  temperature. 

5.  In  grave  cases  of  scarlet  fever,  and  in  those  complicated 
with  gastro-intestinal  disturbances,  indicanuria  becomes  super- 
added to  peptonuria. 

Propeptofie. — Propeptone,  according  to  Heller,  may  occur  in 
scarlet  fever,  not  only  with  albumin,  but  even  when  no  evi- 
dence of  renal  disease  is  apparent.  He  does  not  regard  it  as 
unfavorable  from  a  prognostic  standpoint. 

It  may  be  well  to  remember  that  Von  Koppen  has  noticed 
the  existence  of  propeptone  in  the  urine  of  the  insane,  espec- 
ially of  acute  maniacal  and  excited  cases. 

Bile.  —  Bile  may  be  found  in  the  urine  of  children  as  in 
adults. 

It  is  chiefly  in  cases  of  icterus  neonatorum  that  we  see  it.  In 
severe  cases  of  icterus  neonatorum,  the  urine  is  high-colored 
from  bile  pigment  and  stains  the  linen.  Malarial  and  mias- 
matic poisons  and  phosphorus  poisoning  are  sometimes  causes 
of  the  condition  in  older  children.  Disappearance  of  biliary 
coloring  matter  from  the  urine  is  the  first  sign  of  improvement, 
and  will  be  seen  sometimes  considerably  before  the  jaundiced 
hue  of  the  skin  is  lost.  When  bile  is  present  in  urine,  albu- 
min is  also  found  in  small  amounts. 

Sugar. — According  to  Neumann,  there  is  found  in  all  chil- 
dren's urine  small  quantities  of  a  substance  which  reduces  the 
alkaline  copper  test-liquid.  This  substance  is  especially  notice- 
able in  cases  of  severe  nervous  or  digestive  disorders.  Sugar 
itself,  however,  in  appreciable  quantities  is,  as  a  rule,  significant 
of  diabetes,  if  found  permanently  in  the  urine  of  children.  (See 
Diabetes.) 

Acetone  and  Diacetic  Acid. — Acetone  is  found  in  the  urine  of 
children  under  the  following  conditions  : 

1.  In  very  small  quantities  in  healthy  children. 

2.  In  febrile  diseases  of  children,  increasing  with  fever  and 
diminishing  with  its  decline. 

3.  In  sudden  epileptiform  convulsions  it  is  enormously 
increased  in  quantity,  but  cannot  be  regarded  as  the  cause  of 
eclamptic  seizures  in  general. 

4.  In  diabetes  mellitus. 

Schrack  finds  acetone  in  the  urine  of  children  not  infre- 
quently, especially  in  febrile  affections  and  in  acute  gastro- 
intestinal derangements.  It  may,  however,  be  absent  even  in 
high  and  continuous  pyrexia.  Diacetic  acid  he  finds  also  quite 
frequently,  and  almost  constantly  in  high  and  continued  fever, 


430  THE  DISEASES  OF  CHILDREN. 

and  quite  commonly  in  the  acute  infectious  processes,  even  if 
there  be  but  little  attendant  fever,  as  is  also  the  case  with 
acetone. 

Diacetic  acid,  according  to  Binet,  occurs  in  the  urine  com- 
monly in  febrile  diseases  of  children,  but  it  is  not  found  uni- 
formly in  all  febrile  conditions  ;  it  presents  no  definite  relations 
to  the  intensity  of  the  fever,  the  dyspnoea,  nor  digestive  dis- 
orders. It  is  especially  frequent  in  scarlet  fever,  and  in  some 
doubtful  cases  its  presence  and  degree  may  be  regarded  as  of 
some  diagnostic  value.  Binet  found  it,  using  the  ferric  chloride 
reaction,  in  lo  cases  out  of  23  in  pneumonia  and  broncho- 
pneumonia; in  16  out  of  26  of  measles;  in  27  out  of  34  of 
scarlatina  ;  in  4  out  of  4  of  erysipelas  ;  in  only  1 1  out  of 
31  in  diphtheria;  in  2  out  of  4  of  typhoid  ;  in  2  out  of  4  of 
tubercular  meningitis;  in  2  out  of  15  of  acute  nephritis;  in 
2  out  of  13  of  various  suppurative  diseases  (i  of  bone  tubercu- 
losis and  I  of  sub-diaphragmatic  abscess). 

Diacetemia  is  said  by  Von  Jaksch  to  be  much  more  frequent 
in  children  than  in  adults.  The  child  feels  weak,  has  a  thickly- 
coated  tongue,  often  slight  conjunctival  catarrh,  sometimes 
vomiting,  usually  constipation,  and  very  little  or  no  fever.  In 
two  or  three  days  all  of  these  symptoms,  together  with  the 
diaceturia,  disappear.  In  other  cases  nervous  symptoms  are 
more  marked.  Von  Jaksch  believes  that  all  of  these,  as  well  as 
a  certain  number  of  other  convulsive  attacks  in  children,  are 
the  result  of  anto-intoxication  with  diacetic  acid. 

Chyle. — Chyle  has  been  found  by  Prout  in  the  urine  of  a  male 
infant  18  months  old.  In  older  children  it  often  disappears 
after  rest  in  bed.  The  condition  is  most  common  in  the  tropics. 

In  chyluria  the  urine  is  usually  white  and  opaque,  like  milk ; 
on  standing  awhile  it  sets  spontaneously  into  a  trembling  coag- 
ulum,  which  after  a  time  redissolves  and  breaks  into  flaky  clots. 

Myers,  of  Indiana,  saw  a  case  in  which  a  child  of  eleven, 
female,  had  what  was  supposed  to  be  sciataca  for  five  years, 
until  placing  of  a  seton  in  the  upper  portion  of  the  left  thigh 
revealed  presence  of  chyle  in  the  leg.  After  a  time  the  flow  of 
chyle  from  the  leg  ceased  and  chylous  urine  appeared  in  large 
quantities. 

Organic  Acids. — Lactic,  formic,  acetic,  and  hippuric  acid  are 
said  to  be  present  in  some  cases  of  leukemia,  but  absent  in 
others  hence  are  of  little  or  no  diagnostic  import. 

Allantoin. — This  substance  is  found  in  the  urine  of  new-bom 
children  within  the  first  eight  days  after  birth. 

Pyrocatechin. — This  substance,  called  alkapton  by  Bodecker, 
has  been  found  in  abnormal  quantity  in  the  urine  of  a  child. 
Urine  containing  it  darkens  on  exposure  to  the  air. 


URINARY  SEDIMENTS.  481 

Urinary  Sediments. — The  urine  of  children  suffering  from 
febrile  attacks  often  contains  a  milky-white  sediment,  due  to 
presence  of  sodium  urate,  which  under  the  microscope  exhibits 
irregular,  opaque,  globular,  and  lumpy  masses,  from  which 
project  spiny  crystals.  These  spiny  crystals,  being  precipitated 
within  the  urinary  passages,  irritate  the  mucous  membrane  of 
the  bladder  or  urethra,  and  may  even  block  up  the  canal  of 
the  latter ;  they  may  also  form  a  nucleus  around  which  calcu- 
lous matter  may  hereafter  aggregate,  since  urates  form  the 
chief  part  of  the  nucleus  in  the  majority  of  urinary  calculi. 
The  great  comparative  frequency  of  vesical  calculi  in  children 
is  not  improbably  owing  to  the  occurrence  of  this  deposit  in 
the  numerous  fugitive  febrile  attacks  to  which  children  are 
subject. 

This  whitish  sediment  of  urates  is  easily  distinguished  from 
phosphates,  in  that  it  is  dissolved  when  heated  in  the  urine 
containing  it.  It  is  not  necessary  to  heat  to  boiling  in  order  to 
dissolve  it. 

The  urate  sediment  is  common  in  fevers.  An  abundant  sedi- 
ment of  urates  may  be  found,  for  example,  in  scarlatina. 

They  are  also  found  in  the  urine  of  chorea,  and  entero-colitis. 
Some  children  seem  specially  liable  to  these  sediments,  and 
appearance  of  them  is  accompanied  by  frequent  desire  to  uri- 
nate ;  at  the  same  time  there  is  evidence  of  general  disturbance^ 
malaise,  etc.  Nux  and  calcarea  will  often  be  found  useful  in 
such  cases. 

Uric  acid  often  occurs  in  the  sediment  of  children's  urine. 
(See  Lithemia.)  Its  appearance  to  the  naked  eye  is  that  of 
red-pepper  grains. 

In  cases  of  flatulence,  the  urine  may  contain  a  whitish 
sediment  of  amorphous  phosphates,  readily  soluble  in  nitric 
acid. 

The  urine  of  the  new-born  sometimes  contains  deposits  of 
calcium  oxalate,  recognized  as  small,  colorless  crystals  of  a 
square  letter-envelope  appearance,  seen  best  with  a  power  of 
400  to  500  diameters.* 

According  to  Parrot  and  Robin,  the  presence  of  crystals  in 
the  urine  of  the  new-born  is  one  of  the  rarest  of  occurrences, 
and  one  which  should  always  lead  us  to  suspect  a  pathological 
condition,  except  in  the  first  days  following  birth,  after  the 
urine,  on  standing,  has  undergone  acid  fermentation. 

Xanthin. — Has  been  found  in  the  urinary  sediment  of  a  ten- 
year-old  child,  who,  three  years  before  had  had  symptoms  of 
renal  colic.     The  crystals  are  whetstone-shaped   and  soluble 


*  See  "  Practitioner's  Guide  to  Urinary  Analysis,"  Gross  and  Delbridge,  Chicago. 


432  THE  DISEASES  OF  CHILDREN. 

when  the  urine  is  heated.  Xanthin  calculi  have  been  met  with 
in  children  in  several  cases.     (See  Calculi.) 

Leucin  and  tyrosin  may  be  found  in  the  urine  of  children  in 
cases  of  acute  yellow  atrophy,  a  very  rare  disease  in  children. 

Cystin. — Has  been  found  in  the  sediment  of  children's  urine, 
in  some  families  occurring  instead  of  uric  acid.  W.  G.  Smith, 
observed  cystin  in  the  urine  of  a  boy  of  eight ;  the  urine  had 
an  odor  suggesting  orris  and  the  sediment  was  green  in  color. 
Making  six  examinations,  he  found  cystin  once.  The  child 
seemed  to  suffer  no  harm  from  its  presence,  not  even  for  years. 

Cystin  has  been  found  in  a  calculus  removed  from  the  bladder 
of  a  boy  six  and  one-half  years  old.  The  urine  prior  to  the 
operation  was  alkaline  and  contained  much  sodium  chloride. 
Directly  after  the  operation  the  urine  became  acid  ;  but  eight 
weeks  later  the  alkaline  reaction  recurred  again  and  cystin  was 
recognized  in  the  sediment.  Cystin  was  found  by  Toel  in  the 
urine  of  two  girls,  partly  in  solution  and  partly  as  a  sediment. 

Fat  in  the  Urine. — A  case  is  recorded  by  Drecker  in  a  female 
child  of  twenty-eight  rnonths.  In  the  surface  of  the  urine 
floated  a  layer  of  butter-like  substance,  which,  on  application  of 
heat,  appeared  like  ordinary  fluid  fat.  The  urine  then  became 
milky,  and  looked  like  thin  milk-broth  with  fat  floating  on  it. 
It  had  a  peculiar  aromatic  odor,  diflferent  from  that  developed 
ordinarily  when  urine  is  boiled.  A  drop  on  blotting  paper 
made  a  greasy  mark,  not  disappearing  on  drying.  Heated  with 
liquor  potassae  it  saponified.  It  also  gave  other  proofs  of  be- 
ing fat.  It  was  present  in  4,35  grams  in  every  100  C.  c,  or 
about  22  grains  to  the  fluidounce.  The  child  was  dull,  sleepy, 
very  thirsty;  perspiration  had  unpleasant  odor ;  there  was 
furred  tongue  and  vomiting ;  five  or  six  times  daily  a  white, 
pap-like  stool,  with  dark  streaks  through  it,  occurred  ;  the  face 
was  swollen  ;  there  was  ascites ;  there  was  tenderness  over 
kidneys  ;  skin  dry,  cool,  and  on  upper  arm  finely  desquamatory. 
No  cause  for  the  condition  of  the  urine  could  be  given.  She 
had  been  very  ill  four  months  previous  with  catarrhal  symp- 
toms of  lungs  and  stomach  from  which  she  had  apparently 
recovered  in  three  weeks. 

Epithelia. — The  various  epithelia  may  be  found  in  the  urine 
of  children  as  in  adults.  It  is  only  when  the  sediment  is  very 
abundant,  pointing  to  an  exaggerated  desquamatory  condition; 
that  our  attention  is  called  to  the  condition.  According  to 
Parrot  and  Robin,  mucus  or  hyaline  cylinders  are  not  found 
at  all  in  the  urine  of  the  new-born  in  the  state  of  health.  Epir 
thelia  from  the  bladder,  urethra,  and  vagina,  together  with 
more  rarely,  those  from  the  tubes  of  Bellini,  are  found  in  the 
urine  of  the  new-born. 


GENERAL  SUMMART.  433 

URINE   OF  THE   NEW-BORN. 

General  Summary. — Parrot  and  Robin  draw  the  following 
conclusions : 

"I.  The  urine  of  the  new-born  child  is  colorless,  inodorous, 
thin,  of  great  refraction,  clear  and  limpid,  of  a  mean  density  of 
1003-1004.  The  quantity  passed  in  twenty-four  hours,  from 
the  6th  to  the  30th  day,  varies  from  100  to  300  c.  c. 

"The  morning  emission  is  from  10  to  30  c.  c.  A  new-born 
child  urinates  four  times  more  than  an  adult  for  each  kilo- 
gram of  body-weight. 

"2.  During  the  first  two  days  the  urine  is  more  colored,  more 
scanty,  more  dense,  and  sometimes  opalescent. 

"  It  presents  the  same  characteristics  with  children  whose 
alimentation  is  defective.  The  sex,  the  age  and  the  tempera- 
ture do  not  exert  any  influence  upon  the  physical  characters. 

"3.  It  is  not  sedimentous,  but,  on  standing,  it  lets  fall  a 
very  small  quantity  of  anatomical  elements,  to  wit :  cells  of 
the  bladder,  of  the  urethra,  of  the  vagina,  and  more  rarely, 
in  the  first  days  of  life,  cells  detached  from  the  tubes  of 
Bellini. 

"  In  circumstances,  quite  exceptional,  the  urine  may  give  a 
very  light  deposit  of  uric  acid  crystals,  or  of  oxalate  of  lime,  or 
of  urate  of  soda  (the  first  day's  urine — insufficient  or  vicious 
alimentation,  etc.) 

"  Vegetable  ferments  appear  to  develop  in  it,  more  rapidly 
than  in  the  urine  of  adults. 

"4.  The  test  paper  shows  an  acid  reaction.  The  acidity  of 
the  urine  indicates,  most  usually,  too  long  an  interval  between 
the  nursings,  and,  in  a  certain  number  of  cases,  may  indicate  a 
pathological  state. 

"5.  Itcontains,  per  liter,  3.03  grams  of  urea  and  0.80  gram  per 
kilogram  from  a  child  weighing  3,850  grams.  But  in  the  twen- 
ty-four hours,  the  new-born  child,  from  1 1  to  30  days  old,  passes 
about  0.91  gram  of  urea  and  0.23  gram  per  kilogram  of  its 
weight. 

"6.  The  age,  the  weight,  and  the  temperature  probably 
influence  the  quantity  of  urea ;  hence  the  urine  of  two  chil- 
dren, whose  age,  weight,  and  temperature  differ,  present  un- 
equal quantities  of  urea;  before  explaining  this  difference  by  a 
pathological  state,  we  must  be  sure  that  the  excess  of  urea 
passes  the  limits  which  we  have  fixed  for  the  variations  due  to 
these  causes. 

"7.  There  exists  a  constant  relation  between  the  quantity 
of  urea,  the  color,  and  the  reaction  of  the  urine ;  so  that  the 
inspection  of  the  urine  and  its  reaction  permit  us  to  appre- 
D.  C— 28 


434  THE  DISEASES  OF  CHILDREN. 

ciate,  clinically,  the  proportion  of  urine  without  reagent  or 
analysis. 

"8.  Traces  of  uric  acid  normally  exist  in  the  urine  of  new- 
born children,  but  their  quantity  cannot  be  determined.  The 
urine  of  the  first  days  contains  more  of  this  than  subsequently. 

"  9.  It  does  not  contain  extractive  matters  clinically  appreci- 
able, but  it  contains  hippuric  acid  and  allantoin. 

"  10.  In  no  circumstance  does  the  normal  urine  of  the  new- 
born, or  of  the  fetus,  contain  albumin. 

"II.  Chlorides  and  phosphates  are  found  in  the  urine,  the 
quantities  of  which  vary  according  to  age  and  alimentation, 
also  sulphates  of  lime,  magnesia,  potassa,  and  soda. 

"  12.  It  produces  no  reducing  action  upon  the  liquor  of  Bar- 
reswil  (sugar  test). 

"  13.  The  new-born  ingests,  in  twenty-four  hours,  and  per 
kilogram  of  his  weight,  twice  as  much  nitrogen  as  the  adult ;  he 
passes  six  times  less  by  the  urine,  although  he  retains,  at  least, 
as  much  oxygen  ;  hence  he  burns  less  while  absorbing  more  of 
the  combustible  and,  at  least,  as  much  of  the  burner. 

"  This  excess  of  assimilation  over  disassimilation,  experiment- 
ally demonstrated,  is,  in  relation  with  the  daily  increase  of 
weight,  an  augmentation  in  which  a  portion  of  the  oxygen 
absorbed  must  take  part. 

"  14.  The  new-born  child  excretes  less  chlorides  than  the 
adult,  only  because  he  takes  in  a  much  less  quantity. 

"  15.  The  variations  of  urea,  according  to  age,  weight,  and 
temperature,  are  easily  explained  by  the  modifications  exerted 
upon  the  nutrition,  by  these  influences. 

"  16.  When  the  urine  of  a  new-born  child  is  modified,  in  one 
of  its  characteristics,  beyond  the  limits  which  we  have  laid 
down,  we  may  think,  first,  of  an  irregularity  in  the  alimenta- 
tion, then  of  a  morbid  state. 

"  17.  Circumstances  exist  where,  according  to  the  mode  of 
grouping  the  alterations  of  the  urine,  we  may  determine  the 
existence  of  a  special  pathological  state,  or  of  a  particular 
symptom  (edema  of  the  new-born,  diarrhea,  etc.). 

"  18.  In  other  cases,  the  study  of  the  urine  allows  us  to  fore- 
see the  near  approach  of  particular  accidents,  such  as  edema, 
athrepsia,  etc.  In  fact,  a  lesion  of  nutrition  evidently  precedes 
the  appearance  of  external  signs  of  these  affections,  and  the 
child  is  already  sick,  even  when  no  symptom  outwardly  reveals 
this  state  of  suffering,  the  extent  of  which  is  shown  by  the 
alterations  of  the  urine." 


CHAPTER  II. 

THE  URINE  IN  VARIOUS  DISORDERS  OF  CHILDHOOD. 

Masturbation  in  Female  Children. — Dr.  Charles  Heitzmann, 
of  New  York,  recently  demonstrated  to  me  the  diagnosis  of 
masturbation  in  female  children  by  means  of  microscopical  ex- 
amination of  the  urine.  The  case  was  a  child  of  nine  years ; 
the  urine  contained,  in  addition  to  the  large  epithelia  from  the 
upper  layers  of  the  vagina,  connective  tissue  shreds,  epithelia 
from  middle  layers  of  the  vagina,  epidermal  scales  from  the 
nymph  ae,  fat  granules  of  sebaceous  origin  (smegma)  and 
Bartholinian  epithelium.  Heitzmann's  diagnosis  was  intense 
vaginitis,  vulvitis,  and  Bartholinitis  due  to  rubbing.  The 
child  was  watched  by  the  parents  and  the  diagnosis  confirmed. 
Dr.  Heitzmann  tells  me  that  arriving  at  a  similar  diagnosis  in 
some  five  or  six  other  cases,  the  children  were  watched  and 
caught  in  the  act  in  every  case.  The  important  point  in  the 
diagnosis  is  discovery  of  connective  tissue  shreds  in  the  urine 
in  female  children  not  suffering  from  the  other  disorders  in 
which  connective  tissue  is  regularly  found. 

Tetanus. — In  tetanus  we  find  diminished  quantity  of  urine, 
of  high  color.  There  is  difficult  micturition  and  occasionally 
the  catheter  is  required. 

Fevers. — The  twenty-four  hours  quantity  is  diminished  and 
amorphous  urates  are  deposited  as  the  urine  cools ;  if  there  is 
temporary  retention  of  urine  then  the  hedgehog  crystals  of 
sodium  acid  urate  are  found ;  during  convalescence  the  sedi- 
ment  will  contain  simple  phosphates  and  sometimes  uric  acid 
or  calcium  oxalate,  A  trace  of  albumin  may  be  temporarily 
found  during  the  febrile  attack. 

Typhoid  Fever. — The  features  are  as  follows:  There  may  be 
transient  albuminuria,  but  casts  are  rarely  found  ;  the  bacillus 
typhosus,  if  found  at  all,  only  occurs,  it  is  said,  in  the  sediment 
of  albuminous  urine.  Retention  of  urine  may  occur  and  the 
catheter  need  to  be  used  occasionally  ;  if  the  catheter  be  not 
properly  disinfected,  urethritis,  vesical  catarrh,  and  even  epi- 
didymitis may  ensue.  Polyuria  in  the  course  of  tyhoid  fever 
in  children  has  been  remarked. 

Spinal  Paralysis. — In  the  spinal  paralysis  of  children,  mictu- 
rition is  sometimes  a  little  disturbed  at  the  beginning  of  the 

(435) 


436  THE  DISEASES  OF  CHILDREN. 

disease ;  but  in  most  cases  this  disturbance  completely  disappears 
later. 

Migraine. — In  cases  of  persistent  headache,  look  for  constant 
or  frequent  appearance  of  urates,  uric  acid,  and  calcium  oxalate  ; 
the  latter,  if  found,  point  to  uricemic  (lithemic)  origin  of  the 
headache.    (See  Uricemia.) 

Whooping  Cough. — Involuntary  evacuations  of  urine  some- 
times occur  in  whooping  cough,  following  violent  contraction 
of  the  abdominal  muscles. 

Schiltema  records  a  case  of  acute  nephritis  occurring  after 
whooping  cough  in  a  child  two  years  of  age.  Mircote  declares 
that  the  kidneys  are  affected  in  whooping  cough  in  about  twelve 
per  cent,  of  the  cases,  and  believes  that  the  renal  affection  is 
due  to  venous  stasis,  caused  by  obstruction  of  the  vena  cava 
through  the  violent  paroxysms  of  coughing. 

Diphtheria. —  In  simple  or  follicular  sore  throat,  albumin 
rarely,  if  ever,  occurs  in  the  urine,  while  in  diphtheria  a  trace 
of  albumin  is  very  common.  A  greater  or  less  degree  of  albu- 
minuria exists  in  most  of  the  severe  cases,  usually  when  the 
disease  is  at  its  height,  less  often  at  a  later  period.  A  few 
casts  may  be  found,  but  seldom  much  blood. 

Bouchut  and  Erupis  have  found  albuminuria  in  66  per  cent, 
of  their  cases.  S^e  in  50  per  cent,  of  his,  Barbier  in  75  per 
cent.,  Sann^  in  224  cases  out  of  410,  and  J.  Lewis  Smith  in  24 
out  of  62  consecutive  cases. 

It  may  occur  as  early  as  the  first  day,  though  rarely,  and  a 
large  majority  of  the  recorded  instances  have  been  between  the 
first  and  eleventh  days.  The  urine  differs  in  appearance  from 
that  of  scarlet  fever,  by  being  apparently  normal  to  the  naked 
eye.     It  is  sometimes  present  even  in  mild  attacks  of  diphtheria. 

As  a  rule,  the  albuminuria  does  not  usually  tend  to  a  fatal 
result,  but  in  severe  cases,  with  other  symptoms  unfavorable,  a 
large  proportion  of  albumin,  together  with  marked  diminution 
of  urine,  constitute  an  unfavorable  prognostic  sign.  In  some 
cases,  in  a  mild  diphtheritic  attack,  urine  may  become  scanty, 
highly  albuminous,  and  death  result.  In  some  few  cases  blood 
may  be  found  in  the  urine. 

Capillary  Bronchitis. — Simon  recommends  careful  surveil- 
lance of  the  secretion  of  urine  in  the  management  of  capillary 
bronchitis  in  infants.  The  suppression  of  urine  may  be  the 
principal  cause  of  dyspnea.  If  this  occurs,  he  gives  digitalis  in 
15  c.  gm.  (2^  grains)  doses  of  powdered  leaves  in  infusion, 
three  times  in  twenty-four  hours.  At  the  same  time  he  places 
a  cataplasm  over  the  kidneys,  and  also  uses  dry  cups.  The 
cardiac  contractions  take  on  more  regular  rhythm  and  the  uri- 
nary secretion  is  restored. 


URINE  IN  VARIOUS  DISORDERS.  437 

Measles. — Montefusco  found  the  urine  diminished,  chlorides 
diminished,  sulphates  and  phosphates  sometimes  increased  in 
this  disease.*     Rarely  was  a  trace  of  albumin  found. 

Loeb  has  found  propeptone  (hemialbumin)  in  the  urine  of  9 
patients  with  measles  out  of  12,  in  which  he  examined  the  urine 
for  it.  The  reaction  was  obtained,  as  a  rule,  for  about  two  days 
at  the  beginning  of  the  affection,  after  the  temperature  had  be- 
gun to  go  down,  but  before  the  rash  had  disappeared.  He 
suggests  that  perhaps  the  skin  affection  is  connected  with  its 
formation.  Nitric  acid  added  cautiously  to  the  urine,  drop  by 
drop,  produces  a  white,  flocculent  precipitate  dissolved  by  heat, 
but  reappearing  upon  cooling,  if  propeptone  is  present. 

Suppression  of  Urine. — Cases  of  suppression  of  urine  in  chil- 
dren occur,  especially  in  connection  with  the  acute  nephritis  of 
scarlet  fever,  or  in  scarlet-fever  dropsy  without  albuminuria. 
Cases  of  complete  suppression  have  been  known  to  occur  in 
children  after  catching  cold.  Overdoses  of  drugs,  as  cantharides, 
turpentine,  lead,  and  irritants  generally,  may  cause  it  through 
hyperemia  of  the  kidneys.  Roberts  reports  a  case  in  connec- 
tion with  scarlet-fever  dropsy  without  albumin,  in  which  the 
child,  seven  years  old,  voided  only  two  drachms  in  twenty-four 
hours  ;  it  was  of  a  deep  saffron  color,  highly  concentrated  ;  it 
contained  no  albumin,  but  casts  were  found.  The  total  quan- 
tity of  urine  voided  in  the  entire  last  seven  days  of  life  was  but 
six  or  seven  ounces. 

Janeway  saw  one  case  after  measles  in  which  a  child  of  seven 
passed  but  a  quart  of  urine  during  an  entire  week,  without 
albumin,  blood,  or  casts,  the  specific  gravity  being  1030. 

Eclampsia. — In  eclampsia,  Simon  observes  that  the  secretion 
of  urine  is  entirely  suspended,  and  subsequent  discharge  of  it 
announces  the  approaching  termination  of  the  attack,  or  the  end 
of  a  series  of  attacks. 

Fibroid  Contraction  of  the  Kidneys. — Fibroid  contraction  of 
the  kidneys  was  noticed  by  Fenwick  in  a  case  of  a  girl  of  nine 
years,  who  had  been  healthy  until  about  seven  and  a  half  years 
of  age,  when  she  had  an  attack  of  measles  and  was  never  sub- 
sequently well.  Six  weeks  before  death  she  was  passing  50 
to  65  ounces  of  urine — specific  gravity  loio  to  1012 — with  one 
fourth  albumin  and  casts  of  various  kinds.  There  was  hyper- 
trophy of  the  heart  and  high  tension.  Ophthalmoscope  showed 
double  neuritis.  A  fortnight  before  her  admission  to  the  hos- 
pital she  had  a  severe  fit,  was  universally  convulsed,  and  lay 
unconscious  for  three  days.     When  she  recovered  consciousness 


*  It  is  not  stated  whether  the  increase  in  these  solids  was  relative  or  absolute;  relative 
increase  is  probably  meant. 


438  THE  DISEASES  OF  CHILDREN. 

she  was  practically  blind,  but  partly  recovered  vision.  She  died 
three  months  after  the  first  complaint  of  visual  defect. 

Dermoid  Cyst. — Hair  may  be  found  in  the  urine  coming  from 
a  dermoid  cyst  discharging  into  the  urinary  passages.  Ralfe 
mentions  a  case  in  a  child  in  which  an  apparent  hernia  was 
discovered,  but  was  found  to  be  irreducible.  The  child  became 
ill  and  feverish,  the  urine  cloudy  and  albuminous,  and  the 
swelling  disappeared.  Later  the  urine  cleared  up,  and  ceased 
to  contain  albumin,  but  an  abundance  of  fine  hair  was  passed 
with  the  urine.  The  hair,  collected  and  examined,  consisted  of 
three  varieties  :  (i)  very  fine,  short,  straight  hair,  closely  matted 
together  by  a  sticky,  sebaceous  substance,  having  somewhat 
the  appearance  of  felt ;  (2)  short,  crisp,  curly  hairs,  somewhat 
resembling  wool ;  (3)  some  longer  fibers,  resembling  in  all  re- 
spects human  hair,  colored  either  deep  coal-black,  or  else  bright 
vermilion-red,  and  from  a  quarter  of  an  inch  to  two  inches  long. 
The  discharge  of  hair  caused  the  child  no  discomfort. 


CHAPTER    III. 

ACUTE   NEPHRITIS. 

Definition  and  Synonyms. — Acute  inflammation  of  the  kid- 
neys ;  acute  Bright's  disease.  Under  the  head  of  acute  nephritis 
are  considered  the  various  forms  most  common  in  childhood, 
as  diffuse,  exudative,  etc. 

Etiology. — Scarlatina  is  the  most  common  cause  of  the  acute 
(diffuse)  nephritis  in  those  under  sixteen  years  of  age.  In  some 
cases  acute  nephritis  is  primary  in  children.  Acute  nephritis 
may  result  from  administration  of  poisons,  or  be  secondary  to 
a  number  of  disorders,  as  diphtheria,  small-pox,  typhoid,  etc. 
Acute  nephritis  (exudative)  may  occur  as  a  complication,  and 
not  as  a  sequela,  of  scarlatina,  diphtheria,  and  many  infectious 
diseases.  Acute  nephritis  in  children  may  follow  exposure  to 
cold. 

The  scarlet  fever  nephritis  is  now  regarded  as  chiefly  microbic 
in  origin,  though  it  is  claimed  that  exposure  to  cold  will  often 
induce  an  attack. 

Rasch  believes  that  the  ear  may  sometimes  be  the  focus 
from  which  the  kidneys  receive  the  infection,  inasmuch  as  he 
found  a  case  of  otitis  media  acuta,  which  was  followed  by  acute 
nephritis.  He  points  to  the  necessity  of  examining  the  ears  of 
small  children  when  the  origin  of  infection  cannot  be  found 
elsewhere. 

Pathology. — Cases  of  acute  nephritis  most  commonly  seen  in 
childhood  are  post-scarlatinal.  The  tendency  of  modern  inves- 
tigations is  to  show  that  this  disorder  is  a  complex  state  of  both 
tubal  and  interstitial  change ;  hence  the  term  acute  diffuse 
nephritis. 

Delafield  distinguishes  two  forms,  exudative  and  diffuse,  the 
former  essentially  transitory,  marked  merely  by  exudation  of 
the  albuminous  constituents  of  the  blood  ;  the  latter  by  pro- 
duction of  new  connective  tissue.  Acute  exudative  nephritis 
is  then  not  likely  to  become  chronic,  while  diffuse  nephritis 
proper  is  likely  to  persist.  Clinically  it  is  difficult  to  distin- 
guish acute  exudative  nephritis  from  acute  diffuse,  except  in 
cases  of  exudative  where  there  is  excessive  production  of  pus 
in  which  certain  symptoms  are  tound.     (See  Symptoms.) 

Symptoms. — The  symptoms  of  post-scarlatinal  nephritis  are 

(439) 


440  THE  DISEASES  OF  CHILDREN. 

usually  the  following:  On  the  14th,  20th,  21st,  or  22d  day  aft- 
er invasion  of  scarlet  fever  there  is  usually  increased  tempera- 
ture, perhaps  headache,  pallor,  vomiting,  possibly  convulsions  ; 
micturitions  may  be  increased  in  frequency,  and  pain  be  felt  in 
back  and  region  of  the  bladder.  Edema  is  present,  first  in 
tissues  about  inferior  eyelids,  then  in  lower  extremities,  upper 
extremities,  until  finally  there  is  general  anasarca.  Drowsiness 
or  stupor  may  be  present.  Cough,  diflficulty  of  breathing,  in- 
termittent pulse,  together  with  scanty,  bloody  urine,  highly 
albuminous  and  containing  casts,  complete  the  picture.  Varia- 
tions in  the  symptoms  may  be  noticed  ;  in  some  cases  convul- 
sions are  the  first  symptoms,  in  others  obstinate  vomiting. 
Goodhart  speaks  of  a  case  in  which  hematuria,  scanty  urine, 
and  asthenia  were  the  only  symptoms.  Delafield  speaks  of  cases 
in  which  the  urine  contains  pus  (acute  exudative  nephritis,  with 
much  production  of  pus),  in  which  dropsy  is  absent  or  very 
slight  and  the  entire  clinical  picture  is  that  of  acute  meningitis  : 
marked  fever  and  prostration,  restlessness,  sleeplessness,  de- 
lirium, headache,  stupor.  The  patients  lose  flesh  and  strength 
and  pass  into  the  typhoid  state.  When  such  symptoms  are 
encountered  following  scarlet  fever,  they  are  highly  suspicious  ; 
diflficulty  in  establishing  the  diagnosis  is  encountered  early  in  the 
disorder,  when  the  urine  may  not  be  scanty  nor  contain  albu- 
min, casts,  or  blood  ;  but  later  in  the  disease  the  last  three 
may  be  found,  though  sometimes  they  are  entirely  absent. 
(In  some  cases  no  symptoms  except  the  condition  of  the  urine 
are  noticed.  Aldrich,  of  Minneapolis,  saw  a  case  following 
typhoid  fever  in  which  a  boy  of  ten,  during  nine  months  of 
treatment,  would  not  admit  that  he  was  sick,  although  during 
eight  months  of  the  time  albumin  averaged  from  a  third  to  a 
sixth.     Such  cases  are  better  regarded  as  sub-acute.) 

Symptoms  of  acute  primary  nephritis  are  often  misleading, 
inasmuch  as  there  is  no  history  of  scarlatina  to  arouse  our  sus- 
picions. 

E.  L.  Holt  speaks  of  a  number  of  cases,  in  which  the  symp- 
toms attracted  attention  to  the  brain  or  digestive  system  ;  there 
was  fever,  rapid  pulse,  peculiar  respiration,  and  nervous  symp- 
toms. In  two  other  cases,  he  found  the  predominating  symp- 
toms, continuous  temperature  of  a  high,  remittent  type, 
dullness,  apathy,  anemia,  and  mild  gastro-intestinal  symptoms 
without  dropsy  or  suppression  of  urine.  The  last  two  cases 
lasted  17  and  22  days  respectively  and  both  died.  The  tem- 
perature ranged  from  101°  to  105°.  Goodhart  mentions  a  case 
not  following  scarlet  fever,  in  which  the  symptoms  were  as 
follows ;  the  child  felt  sick,  had  'stomach-ache  and  was  feverish. 
She  afterward  vomited  repeatedly,  was  pale,  drowsy,  ashy  in 


ACUTE  NEPHRITIS.  441 

appearance,  with  sub-normal  temperature,  cold  extremities, 
and  imperceptible  pulse.  The  heart  sounds  were  rapid  and 
irregular.  The  urine  contained  one-tenth  albumin  and  casts. 
Suppression  of  urine  followed,  continuing  for  many  hours,  and 
just  before  death  she  had  convulsions.  The  disease  lasted 
seven  days. 

Seyournet*  has  studied  a  type  of  albuminuria  among  children 
of  the  age  of  from  eleven  to  sixteen  months.  A  great  many  of 
the  patients  had  been  brought  up  on  the  bottle,  having  been 
fed  on  unsuitable  food,  causing  distention  of  the  abdomen  or 
stomach,  or  occasionally  enlargement  of  the  liver,  or  intestinal 
disorders,  accompanied  by  vomiting  or  diarrhea.  He  believes 
this  special  form  of  albuminuria  to  be  of  an  infectious  character, 
and  traces  it  back  pathogenetically  to  certain  toxic  substances, 
which  are  generated  by  abnormal  fermentation  in  the  bowels. 
These  substances  are  absorbed  by  the  bowels  and  pass  to  some 
extent  into  the  kidneys.  They  produce  congestion  in  the  renal 
tissue,  which  may  lead  to  inflammation  of  the  kidneys.  One 
of  Dr.  Seyournet's  little  patients  had  scarlet  fever  twenty-two 
days  after  convalescence  from  this  albuminuria.  It  is  evident 
from  this  fact,  that  it  was  not  scarlatinal  albuminuria.  It  was 
usually  accompanied  by  anuria,  whereby  the  congested  condi- 
tion of  the  kidneys  was  intensified.  With  some  of  the  patients 
the  daily  evacuation  of  urine  was  only  half  an  ounce.  In  one 
case  the  patient  passed  no  urine  for  more  than  forty-eight 
hours.  Notwithstanding  this,  no  uremic  symptoms  appeared. 
It  was  in  most  cases  only  the  anuria  which  led  to  the  urine  be- 
ing examined  for  albumin.  The  result  of  the  examination  in 
in  each  case  was  positive.  A  strongly  marked  feature  of  this 
disease  is  the  edema  of  the  feet,  sometimes  also  of  the  hands 
and  of  the  eyelids  and  face,  but  the  latter  were  not  always  af- 
fected. The  quantity  of  albumin  varied  from  a  drachm  to  ten 
drachms  per  diem  (60  to  160  grains,  4  to  40  grams).  The 
duration  of  the  disease  was  from  two  to  four  weeks.  The  treat- 
ment consisted  in  giving  milk,  which  in  some  cases  was  mixed 
with  lime-water.  Systematic  massage  of  the  lumbar  regions 
was  also  employed  in  order  to  relieve  the  congestion  of  the 
kidneys.     Various  drugs  were  also  given. 

Another  case  recorded  by  Goodhart,  was  that  of  a  boy,  who, 
after  being  weaned  from  the  bottle,  had  intense  thirst,  but  was 
otherwise  thought  to  be  well.  At  the  age  of  three  he  had  a 
sudden  and  severe  attack  of  fever  and  vomiting,  from  which  he 
recovered.  After  his  recovery  he  had  night  terrors,  and  became 
subject  to  severe  attacks  of  tetany  and  periodic  attacks  of 

*  The  Lancet. 


442  THE  DISEASES  OF  CHILDREN. 

vomiting.  His  urine  was  always  of  low  specific  gravity  and 
sometimes  contained  albumin  and  sometimes  not.  There 
were  no  casts ;  dropsy  was  absent.  Once  a  month  he  would 
have  a  relapse,  tetany  reappearing,  urine  becoming  scanty  and 
loaded  with  albumin.  He  died  in  one  of  these  attacks,  coma- 
tose, and  in  a  state  of  opisthotonos. 

It  may  be  remarked  here  that  in  all  obscure  diseases  of  chil- 
dren, in  which  intestinal  disorders  are  prominent,  the  urine 
should  be  frequently  examined. 

An  editorial  in  the  Hahnemannian,  1893,  p.  417,  calls  atten- 
tion to  the  fact  that  albuminuria,  without  the  well-known 
symptoms  of  Bright's  disease,  may  occur  in  children.  The 
younger  the  child,  the  less  characteristic  may  be  the  symp- 
toms. A  simple  high  fever,  or  vomiting,  purging,  and  collapse, 
or  drowsiness  and  mild  convulsive  seizure,  or  simply  anemia 
may  be  the  symptoms.  Nephritis,  without  apparent  cause, 
and  practically  without  indicating  symptoms,  may  occur  in 
children  even  as  young  as  six  months.  The  excellent  prac- 
tical suggestion  is  made  that  to  collect  the  urine  of  infants  for 
examination  the  child  should  be  kept  on  pieces  of  well-boiled 
linen  on  a  rubber  pad  for  some  hours,  or  on  a  sterilized  silk 
sponge.  Enough  urine  can  be  wrung  out  of  these  for  pur- 
poses of  examination.  If  retention  be  present,  a  small  cath- 
eter may  be  used. 

Moussous  speaks  of  two  children  who  had  nephritis  in  the 
course  of  rheumatic  purpura.  The  symptoms  were  articular 
pains,  hemorrhages  beneath  the  skin  and  from  mucous  mem- 
brane of  the  alimentary  canal,  pains  in  the  back,  edema,  occa- 
sional hematuria,  continuous  albuminuria,  and  in  one  case 
hyaline  and  epithelial  casts.  One  of  the  children  died  from 
asthenia,  and  the  kidneys  were  like  the  large  white  kidney, 
only  not  enlarged.  He  regards  the  cases  as  chronic  diffuse 
nephritis. 

Hollopeter  speaks  of  acute  nephritis  in  a  little  boy,  occur- 
ring after  whooping  cough.  The  child  apparently  recovered, 
when  a  relapse  occurred  and  with  it  nephritis  and  uremia  set 
in.  There  was  edema  of  the  lids  and  parts  of  the  body,  to- 
gether with  stupor.     Recovery'  followed. 

Longstreth  describes  the  case  of  a  colored  boy  of  ten,  picked 
up  comatose  in  the  street.  His  pupils  were  dilated.  He  com- 
plained only  of  abdominal  pain,  and  had  been  busy  running 
errands.  Albumin  and  casts  were  found  in  his  urine,  and 
later  he  had  more  convulsions.  No  origin  could  be  found  for 
the  case. 

Course. — Scarlatinal  nephritis  varies  greatly  as  to  course : 
we  may  find  cases  which  begin  to  improve  a  week  or  ten  days 


ACUTE  NEPHRITIS.  443 

after  they  have  begun  ;  or  cases  which,  after  progressing  favor- 
ably, suddenly  grow  worse  ;  or  cases  which  may  be  so  violent 
in  onset  as  to  cause  death  in  less  than  a  day.  Death  occurs 
within  the  first  eight  or  ten  weeks  usually ;  after  this  time,  if 
the  patient  lives,  it  is  to  be  regarded  as  subacute  or  chronic, 
and  may  persist  a  number  of  years. 

The  following  cases,  which  recovered  completely  from  scarla- 
tinal nephritis,  illustrate  the  condition  of  the  urine  with  reference 
to  duration  of  the  disorder. 

Case  I.  Boy.  14th  of  January  urine  was  highly  acid,  con- 
tained moderate  quantity  of  albumin,  specific  gravity  1026 ; 
sediment  contained  blood,  pus,  renal  epithelium,  hyaline, 
epithelial,  blood,  and  finely  granular  casts,  the  latter  not  very 
numerous.  After  this  analysis  the  case  became  serious,  with 
scanty  urine  and  threatened  uremia;  but  by  March  13  not  a 
trace  of  albumin  nor  any  casts  could  be  found,  and  the  patient 
has  been  well  ever  since,  now  over  a  year. 

Case  2.  Girl,  sister  of  case  i.  January  23,  blood,  epithelial 
casts  and  considerable  pus  were  found  in  the  urine,  albumin 
1-20  of  one  per  cent,  by  weight ;  after  this  the  patient  grew  worse, 
urine  diminished  to  half  a  dozen  ounces  per  diem.  Recovery 
was  slow  ;  on  April  20  a  trace  of  albumin  could  still  be  found 
and  one  or  two  casts.  On  June  3  a  few  granular  casts.  On  June 
28  no  casts  and  a  further  analysis  made  December  15  showed 
the  urine  to  be  normal  in  all  respects. 

Prognosis. — The  patient's  chances  for  recovery  from  scarla- 
tinal nephritis  are  two  out  of  three  ;  but  even  in  apparently 
favorable  cases,  relapses  or  heart  failure  may  occur. 

Relapses  may  occur  any  time,  and  are  marked  by  increase  of 
dropsy,  decrease  of  urine  per  twenty-four  hours,  increase  of 
hematuria  and  albuminuria.  The  danger  now  is  from  uremia, 
or  pulmonary  edema.  Favorable  signs  are  subsidence  of  he- 
maturia, increase  in  quantity  of  urine  per  twenty-four  hours, 
diminution  in  quantity  of  albumin  and  casts,  lessening  of 
dropsy.  Signs  of  heart  failure  are  sudden  feebleness  of  the 
pulse,  which  becomes  also  irregular  and  sometimes  slow.  The 
respirations  become  rapid,  extremities  are  cool,  and  death  may 
result  suddenly  from  collapse. 

Treatment  of  Acute  Nephritis. — /.  Preventive. — It  has  been 
held  that  a  milk  diet  throughout,  in  scarlet  fever,  with  avoid- 
ance of  exertion,  and  of  taking  cold,  in  the  third  week,  is  sufifi- 
cient  to  prevent  the  onset  of  acute  nephritis.  If,  however,  at 
that  time  the  temperature  again  rises  and  the  urine  begins  to 
diminish,  with  headache,  edema,  etc.,  then 

2.  Hygietiic. — Patient  is  to  be  put  to  bed,  wearing  woolen 
night-dress  and  wrapped  in  blankets.     Jaeger  night-clothing  and 


444  THE  DISEASES  OF  CHILDREN. 

bedding  desirable.  Patient  to  be  sponged  daily  with  tepid  water 
containing  a  little  alcohol  ;  each  part  of  the  body  to  be  rubbed 
dry,  after  sponging,  before  another  part  is  wet.  Room  to  be 
about  70°  Fahr.  in  temperature.  Thorough  ventilation  to  be 
secured.  Diet :  if  urine  be  suppressed  or  nearly  so,  arrow- 
root gruel  for  two  days ;  then,  if  urine  more  abundant,  milk  in 
small  quantity  mixed  with  the  gruel,  rice  in  thin  broth,  plain 
rice  pudding.  In  severe  cases,  no  meat  or  fish  for  two  weeks, 
and  milk  only  in  preparation  of  foods.  Grapes,  oranges,  straw- 
berries allowable.  After  the  first  day  or  two  give  pure  spring 
water  freely.  Such  waters  as  Poland,  Bethesda,  Clysmic  desir- 
able. Potatoes,  especially  sweet,  allowable.  When  severe 
symptoms  subside,  exclusive  milk  diet.  Try  the  entire  milk, 
or  if  not  borne,  skimmed  milk,  a  few  ounces  every  two  or  three 
hours,  lime-water  and  milk,  milk  of  magnesia  and  milk.  Or,  if 
constipation,  milk  and  Vichy,  milk  and  carbonic  water.  Bear 
in  mind  also,  peptonized  milk,  peptonized  gruel  and  milk,  pep- 
tonized milk  toast.  The  milk  diet  should  be  continued  for  four 
weeks. 

3.  Remedial. — The  remedies  most  often  found  useful  are 
tnerc.  cor.  terebinth,  ferrum,  digitalis  and  apium  virus. 

The  table  on  following  page  will  serve  as  a  help  in  differ- 
entiating:* 

Searle  thinks  mere.  cor.  the  main  remedy  for  acute  nephritis, 
alternating  it  with  aconite  ox  ferrum  phosphoricum,  and  giving 
warm  baths  (98°  to  100°),  prolonged  to  half  an  hour  or  an  hour. 
Woodward  thinks  nitric  acid  often  serviceable,  and  a  remedy 
which  should  not  be  forgotten.  Gastro-intestinal  symptoms, 
together  with  headache,  are  the  chief  indications  for  use  of  it. 

Joussetf  relies  mainly  on  belladonna,  cantharis,  and  apium 
virus.  He  thinks  belladonna  should  be  used  in  the  beginning, 
when  there  is  fever,  headache,  vomiting,  together  with  scanty, 
bloody  urine.  He  gives  six  drops  of  one  of  the  first  three  dilu- 
tions in  a  glass  of  water,  teaspoonful  every  two  hours.  Can- 
tharis he  uses  after  the  beginning  when  there  is  no  fever,  or 
when  belladonna  has  reduced  the  temperature  in  cases  where 
the  urine  is  highly  albuminous,  bloody,  scanty,  and  passed 
with  much  tenesmus.  Dose  as  of  belladonna;  in  severe  cases 
drop  doses  of  the  tincture  three  times  daily. 

Some  clinicians  advise  acidum  carbolicum  and  kali  bichromicum 
in  the  earlier  stages,  following  with  mere.  cor.  or  mere,  cyan.,  and 
using  apis  in  the  later  stages.  When  serous  effusions  are 
evident,  arsenicuvi,  bryonia,  senega. 


♦Table  X  on  page  124  of  Mitchell's  "  Diseases  of  the  Kidneys." 

\  Paper  translated  from  the  French  by  the  writer  of  this  article  for  the  Columbian  Ex- 
position Congress,  of  1893. 


ACUTE  NEPHRITIS— LEADING  REMEDIES.         445 


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446  THE  DISEASES  OF  CHILDREN. 

For  the  dropsy  resisting  apparently  indicated  homeopathic 
remedies,  Tooker  advises  diuretin,  which  he  has  used  success- 
fully in  a  number  of  cases.  Severe  dropsy,  coming  on  after  the 
acute  stage  of  nephritis,  is  often  easily  reduced  by  diuretin,* 
In  cases  of  mitral  insufficiency  with  insuflficient  compensation, 
digitalis  is  given  first  to  reduce  the  compensatory  disturbance, 
then  diuretin  is  administered  for  the  ascites,  and  anasarca.  Chil- 
dren from  two  to  five  may  take  from  eight  to  twenty-five  grains 
a  day;  children  from  six  to  ten  as  much  as  from  twenty-five  to 
forty-five  grains  in  divided  doses.  The  total  amount  for  the 
day  may  be  dissolved  in  four  ounces  of  warm  water,  with  ten  or 
twelve  drops  of  brandy,  and  say  forty  grains  of  sugar.  In  some 
cases  the  drug  has  been  given  for  weeks  without  signs  of  cu- 
mulative action  or  diminished  therapeutic  effect.  As  a  rule,  if 
in  six  days  it  has  no  effect,  it  is  useless  to  continue  it  any 
longer. 

Sambucus  Nigra. — In  full  doses  has  been  found  to  be  a 
very  prompt  diuretec  in  acute  nephritis  with  anasarca. 

In  the  anemia  following  acute  nephritis,  there  should  be  one 
meal  a  day  of  solid  food,  meat  with  bread  and  butter  ;  during 
the  rest  of  the  twenty-four  hours,  milk.  Bowels  are  to  be 
opened  daily  by  enema  or  simple  laxative.  Internally  /errum, 
supplemented  by  inhalations  of  oxygen  gas.  Boudreaux's  syrup 
of  the  protochloride  of  iron  is  an  excellent  preparation.  In 
the  case  of  a  child  whose  urine  was  brought  to  me  for  examina- 
tion, complete  cure  was  brought  about  by  the  use  of  Bou- 
dreaux's protochloride.  The  symptoms  were  dropsy,  anemia, 
and  albuminous  urine,  containing  numerous  hyaline  casts. 

If  ferrum  fails,  recourse  may  be  had  to  preparations  of  malt 
and  cod-liver  oil. 

COMPLICATIONS   OF  ACUTE   NEPHRITIS. 

Uremia. — In  the  treatment  of  uremia,  with  convulsions 
impending  or  already  present,  application  of  a  large  hot  poul- 
tice to  the  loins  should  be  made  and  it  should  be  changed 
every  three  hours.  The  wet  pack  may  be  used  with  advan- 
tage to  promote  sweating ;  a  thin  blanket  is  wrung  out  of  hot 
water,  and  the  naked  child  is  wrapped  in  it  from  chin  to  feet ; 
a  dry  blanket  is  then  wrapped  round  it  and  loosely  covered 
with  a  mackintosh.  After  an  hour  or  so  the  wet  pack  is 
removed,  and  the  child  swathed  in  a  dry  blanket.  The  pack 
should  not  be  continued  for  any  excessive  length  of  time. 
If  necessary,  the  pack  may  be  repeated  at  intervals  of  four  to 
six  hours. 


*Amer.  Pract.  and  News. 


ACUTE  NEPHRITIS— COMPLICATIONS.  447 

Cupping  the  loins  is  recommended,  but  is  not  suited  to  the 
case  of  young  children. 

Purdy  and  others  recommend  blood-letting ;  "  if  the  child  be 
of  robust  constitution,  and  the  symptoms  do  not  yield  to 
other  measures,  from  two  to  six  ounces  of  blood  may  be  taken 
from  the  arm,  often  with  the  happiest  results."* 

When  one  convulsion  follows  another,  or  other  of  the  lesser 
convulsive  measures  seem  to  threaten,  Goodhart,  instead  of 
bleeding,  prefers  an  ice-bag  to  the  head  and  administration  of 
chloroform,  potassium  bromide,  and  chloral  hydrate,  either  by 
mouth  or  rectum.  The  benzoates  may  also  be  given  internally 
to  prevent  recurrence  of  the  convulsions. 

The  symptoms  of  uremia  are  usually  diminution  in  quantity 
of  urine,  increased  headache,  twitching  of  some  part  of  the  face 
or  extremities,  or  a  general  epileptiform  convulsion,  affecting 
the  whole  body.  There  may  be  but  one  attack,  or  one  may  be 
rapidly  succeeded  by  others  again  and  again,  in  which  case 
there  is  much  danger. 

Searle  speaks  highly  of  lemon-juice  in  the  treatment  of 
uremia;  half  a  pint  in  all  in  twenty-four  hours,  each  dose  mixed 
with  water.  Pilocarpin  is  regarded  as  a  dangerous  agent  in 
the  case  of  children. 

Edema  of  the  Tissues  and  Cavities. — Edema  of  the  lung  is  a 
most  serious  complication.  It  often  sets  in  rapidly  ;  the  phys- 
ical signs  are  those  of  acute  bronchitis,  but  the  face  is  pallid 
or  cyanotic,  there  is  great  dyspnea  and  distress,  and  the  aspect 
of  the  patient  is  that  of  one  not  long  to  live.  The  bowels  should 
be  opened  at  once  and  such  remedies  as  digitalis,  strophanthus, 
etc.,  given.  Stimulants,  if  necessary,  as  brandy,  champagne, 
aromatic  ammonia. 

Hydrothorax  occurs  more  slowly  and  is  usually  a  part  of  the 
general  filling  up  with  water.  It  is  a  dangerous  compHcation. 
Arsenicum  is  the  principal  remedy,  together  with  general 
eliminative  treatment.  If  any  operation  is  to  be  performed, 
aspiration  is  the  best  for  withdrawing  the  liquid. 

Dropsies  of  serous  cavities,  in  general,  require  arsenicum;  par- 
acentesis with  a  very  fine  canula  is  advised  by  Goodhart  for  ab- 
dominal dropsy,  for  relief  of  immediate  symptoms.  ¥  or  anasarca, 
digitalis,  strophanthus,  caffein,  the  benzoates  and  diuretin  are 
to  be  used  first  ;  the  legs  may  be  punctured  (simple  acupunc- 
ture).    Bowels  to  be  opened  freely  and  baths  given. 

Vomiting. — Skimmed  milk  or  iced  Vichy,  iced  champagne. 
Glonoin  is  worth  trying.  Hot  water  will  sometimes  check  the 
vomiting  when  other  measures  fail.     Kreasote  may  be  tried. 

•  Purdy. 


448  THE  DISEASES  OF  CHILDREN. 

Vomiting,  in  cases  where  there  is  uremia,  is  often  an  effort  of 
nature  and  should  not  be  checked  too  suddenly. 

Suppression  of  urine. — (See  Uremia.)  Give  plenty  of  watery 
drinks,  hot  lemonade,  cider,  etc. 

Cardiac  Hypertrophy. —  Symptoms :  displacement  of  apex- 
beat,  accentuation  of  second  sound,  increased  dullness.  Digi- 
talis and  convallaria,  the  latter  in  doses  of  3  drops  of  the  fluid 
extract. 

Acute  Dilatation  of  the  Heart. — Irregular  or  halting  action 
of  the  heart,  frequent,  thready,  fluttering  pulse,  cold  extremi- 
ties, and  frequent  respirations  are  the  symptoms.  It  is  a  very 
serious  complication  and  likely  to  result  in  edema  of  the 
lungs.  Length  of  the  systole,  want  of  sharpness,  or  shuffling 
quality  may  be  noticed. 

The  remedies  are  digitalis,  strophanthus,  and  caffein.  Good- 
hart  advises  tincture  of  digitalis  in  four  or  five  minim  doses 
every  three  or  four  hours,  continued  for  a  day  or  two,  then  left 
off  for  a  day  or  two,  and  begun  again,  if  necessary;  digitalin 
in  doses  of  1-120  of  a  grain  may  be  given  instead;  strophan- 
thus,  in  doses  of  from  2  to  5  minims  of  the  tincture,  or  caffein, 
in  doses  of  one  or  two  grains,  the  latter  together  with  sodium 
benzoate  in  water.  He  thinks  strychnin  in  doses  of  i-icx) 
of  a  grain  by  subcutaneous  injection  one  of  the  most  valuable 
cardiac  tonics  that  we  possess. 

Collapse,  with  slow  pulse  (65  or  even  50),  perhaps  alarmingly 
irregular,  rapid  breathing,  cool  extremities,  is  an  exceedingly 
grave  complication.     Strophanthus  is  probably  the  best  remedy. 

Diarrhea  is  a  common  complication  and  should  rarely  be 
checked  completely  unless  there  is  great  exhaustion,  since 
elimination  is  promoted  by  it. 

Acidity  of  the  Urine. — In  some  cases,  the  highly  acid  urine 
favors  blocking  up  of  the  convoluted  tubules  with  colloid  mat- 
ter; for  the  purpose  of  diminishing  the  acidity,  lithia  waters, 
as  Londonderry,  Buffalo,  or  other  well-known  alkaline  waters, 
may  be  given,  or  lithium  benzoate  in  small  doses,  first  decimal 
trituration;  possibly  grain  doses  of  \he  citrate  of  potash  dis- 
solved in  a  moderate  amount  of  water,  and  given  every  two  to 
six  hours. 

Granular  effervescent  citro-tartrate  of  sodium  may  be  given 
in  five-grain  doses  in  water. 

SUBACUTE    NEPHRITIS. 

This  disorder  may  be  either  idiopathic  or  a  sequela  of  scarla- 
tina and  diphtheria.  Whereas  the  duration  of  acute  nephritis 
is  about  four  weeks,  eight  to  ten  weeks  at  most,  that  of  sub- 


SUBACUTE  NEPHRITIS.  449 

acute  may  be  for  months,  or  even  years.  The  symptoms  come 
on  gradually  and  are  chiefly  the  following :  Anemia,  dropsy, 
loss  of  strength,  nausea,  vomiting,  diarrhea.  The  urine  is  not 
likely  to  be  greatly  diminished  ;  it  may  even  be  increased,  but 
the  amount  of  solids  as  compared  with  that  of  the  water  defi- 
cient ;  i.  e.,  the  quality  of  the  urine  is  poor.  The  arteries  are 
usually  relaxed,  but  sometimes  contracted ;  there  may  be 
inflammation  of  the  retina.     (Delafield.) 

1 .  Hygienic  Treatment. — Removal  of  patient  to  suitable  warm 
climate,  where  out-of-door  life  is  possible,  as  Southern  Cali- 
fornia, the  Bermudas,  the  Arkansas  springs,  Thomasville  in 
Georgia,  Tallahassee  in  Florida.  High  altitudes,  rough  ocean 
voyages  and  long  railway  journeys  to  be  avoided. 

If  the  patient  reside  in  a  cold  climate,  he  must  be  kept  in- 
doors in  stormy  weather,  and  observe  every  precaution  about 
catching  cold  ;  wear  woolens,  etc.  ;  diet  need  not  necessarily  be 
limited  to  liquids,  except  in  acute  exacerbations.  Patient  may 
take  as  much  solid  food  (of  a  non-nitrogenous  character)  and 
fats  as  he  can  digest.  Excessive  use  of  mineral  waters  of  doubt- 
ful utility.  The  patient  should  void  enough  urine  daily  to 
excrete  the  normal  amount  of  urea,  and  when  dropsy  is  to  be 
overcome,  the  amount  of  fluids  taken  by  the  patient  should  not 
exceed  the  amount  of  urine  voided.* 

The  same  general  hygienic  treatment  pertains  to  protracted 
forms  of  acute  nephritis.  The  patient  may  have  to  be  kept  in 
bed  for  a  time,  but  should  be  given  fresh  air  as  soon  as  it  is 
prudent. 

2.  General  Treatment. — The  patient's  bowels  should  be  kept 
in  order  and  the  skin  moist  and  active.  Massage  is  helpful, 
also  inhalations  of  oxygen  gas,  when  there  is  anemia.  (See 
Anemia  under  Acute  Nephritis.) 

3.  Radical  Treatment. — The  remedies  especially  adapted  to 
the  sub-acute  form  are  apis,  digitalis,  ferrum,  mercurius  cor. 
Where  apis  is  indicated,  headache  is  particularly  noticeable.  (See 
indications  already -given  in  table.)  Digitalis  is  useful  when 
edema  and  dropsy,  together  with  cardiac  failure,  are  prominent 
early  in  the  case.  There  is  some  nausea,  but  the  pain  in  the 
back  is  but  slight.  Indications  for  ferrum  have  already  been 
given,  as  have  those  for  mere.  cor.     (See  table.) 

Boudreaux's  iron  is  especially  serviceable  when  ferrum  is  indi- 
cated. Ferrum  phos.  and  the  lactate  of  iron  in  the  lower  deci- 
mals are  said  from  clinical  experience  to  be  useful. 

For  the  high  tension,  glonoi?i  is  the  remedy,  given  in  the 


*  Delafield  Med.  Record,  March  23,  iSSg.  In  some  cases  no  quantity  of  liquid  ingested 
will  bring  up  the  urea  to  normal,  and  the  patient  will  excrete  more  urea  when  voiding  a 
smaller  quantity  of  urine.     See  article  by  writer  in  Hahnemannian  (1893). 

D.  C— 29 


450 


THE  DISEASES  OF  CHILDREN. 


third  decimal  or  upwards  according  to  age  of  the  patient. 
Symptoms  of  high  tension  are  incompressible  pulse,  fullness  in 
the  head,  or  bursting  headache,  etc.  Glonoin  in  triturations 
has  been  found  less  likely  to  cause  aggravation  than  in  dilutions. 
For  coma  without  increased  tension  strophanthus,  spartein,  etc., 
in  small  doses. 

Prognosis. — Very  few  patients  recover  permanently.  Some 
continue  to  get  worse  every  way,  and  die  within  one  or  two 
years ;  some  get  better  after  a  few  months,  then  become  ill 
again,  and  so  go  on  for  years. 

Analysis  of  Urine. — The  following  is  my  analysis  of  the 
urine  in  the  case  of  a  boy  of  fifteen  with  subacute  diffuse 
nephritis : 


Ingredients 

Grams 

per 
Liter 

Grains 

per 
ounce 

Grams 

per 
24  hrs. 

Grains 

per 
24  hrs. 

U  rea 

lO 
6 

O.S 

5 
3 
0.4 

IS 

9 

1.2 

140 

18 

Albumin 

Phosphoric  Acid 

Volume  of  Urine  in  24  hrs 

Specific  gravity 1012 


\  1500 
hofl. 


cc. 

OZ. 


Sediment. —  Blood  corpuscles  ;  pus  corpuscles ;  epithelium 
from  convoluted  tubules ;  hyalin,  epithelial,  granular,  and 
fatty  casts,  together  with  a  few  waxy. 

Patient  anemic,  confined  to  bed  owing  to  loss  of  strength  ; 
edema  of  ankles  and  scrotum,  face  puffy,  heart  action  at  times 
irregular  ;  otherwise  no  symptoms. 


CHAPTER  IV. 


PYURIA  AND   HEMATURIA. 


The  principal  diseases  of  childhood  in  which  pus,  with  or 
without  blood,  is  found  in  the  urine  are  the  following :  Suppura- 
tive nephritis,  pyelitis,  pyonephrosis,  cystitis,  calculous  disease, 
tuberculosis,  cancer. 

When  pus  is  found  in  the  urine  consult  the  table  on  page  452.* 
If  blood  is  a  well-marked  feature  in  the  urine,  consult  also 
the  following  table  :  f 

DIAGNOSIS   IN  HEMATURIA. 


Blood  from  the 

kidneys. 

Blood  from  the 
bladder. 

Blood  from  the 

prostatic  portion  of 

the  urethra. 

Blood  from  the 
urethra. 

Blood  corpuscles 
spherical,  small 
and   brownish. 
Renal    epitheli- 
um small  round- 
ish,   one  -  third 
larger  than  pus 
corpuscles. 

Blood   corpuscles 
spherical,    small, 
brownish,  epithe- 
lium   from   blad- 
der    often     large 
round     (middle 
layers). 

Blood  corpuscles  of 
normal  disk-form, 
with   central    Re- 
pression and  red- 
dish-yellow color. 

Blood  corpuscles 
like  those  from 
neck  of  the  blad- 
der (prostatic 
urethra). 

Albumin     more 
than  blood   ac- 
counts for. 

Albumin  less  than 
blood    accounts 
for. 

Albumin  less. 

Albumin  less. 

Blood  only  during 
micturitions. 

Blood  only  during 
micturitions. 
Urine  more    and 
more     tinged    as 
bladder     empties 
itself. 

Blood  at  the  begin- 
ning  of   micturi- 
tion.    Sometimes 
a  few  drops  at  the 
end  only. 

Blood  flows  from 
meatus  between 
micturitions,  or 
may  be  squeezed 
out.  Blood  in  the 
first  glass  only  on 
micturition. 

Urine   may  con- 
tain casts. 

No  casts. 

No  casts. 

No  casts. 

Clots   rounded, 
corresponding 
to    diameter    of 
ureter. 

Clots   very    large 
and   irregular    in 
shape. 

Clots    leech  -  like, 
ovoid. 

Long,  bougie -like 
clots. 

•Table  X  from  Mitchell's 
^Ibid.  Table  XU. 


■Diseases  of  the  Kidnevs." 


(451) 


452 


THE  DISEASES  OF  CHILDREN. 


o 

a 

'c  2 
°| 

S  P 

a, 
o. 

3 

cn 

Urine  in  first  glass 
turbid,  in  second 
clear. 

Pus    oozes    from 
meatus  between 
micturitions. 

3 
to 

3 

8 

cd  'tj 

Urine  in  first  glass 
will   respond  to 
albumin  tests. 

3      . 
.«  no 

3S 
<u 

£| 

3.S 

<4H 

0 

.!<! 
o 
u 

C 

(U 

.a  u 
— -o 

•ss 

2 

g. 

M icturitions  frequent 
and  painful  at  begin- 
ning and  end.     Urine 
in  first  glass  more  tur- 
bid   than   that  of  sec- 
ond. 

Pus   sediment  shreddj', 
sometimes  surmounted 
by  blood.    Shreds  may 
be  streaked  with  blood. 
Epithelium  from  mid- 
dle   layers    bladder 
(large). 

!2 
'o 

OS 

3 
to 

3 

3 

.2 

y 

03 
41 

Urine  may  contain  more 
albumin  than  pus  ac- 
counts for. 

3 
to 

3 

4; 
.2 

=  •0 
.s       4> 
tn   to 

b   03 

5    4^ 
O    ;- 

•^    41 

c 

0!  C4 

3 

Scalding  urine,  pain  in 
passing  water.     Urine 
in  both  glasses  equally 
turbid,  last  drops  usu- 
ally very  turbid. 

Pus   sediment   sticky, 
clings     to     the    glass. 
Sediment  contains  tri- 
ple phosphate,  bladder 
epithelia,  bacteria.  Pus 
corpuscles     swollen. 
Epithelium  of  bladder 
(middle  layers). 

03 

M 

3 
3 

3 
O 

(J  aj 
OS  c 

4)  — 

Pi" 

Urine  contains  but  little 
albumin  and  that  due 
to    pus.      Ammonium 
carbonate  abundant. 

24  hours'  urine  usually 
normal    or    not   in- 
creased. 

<U 

c 

5  • 
.=  ■> 

el! 
Jo- 

"S 

•    s 
o. 

Q. 
3 
W 

Acute:  febr  i  le  condi- 
tion,    pain     in      back. 
Chronic  :  course  insid- 
ious,   symptoms    may 
not  be  marked. 

Pus  sediment  flocculent, 
not  shreddy  nor  sticky 
in  uncomplicated  cases. 
Pus   corpuscles  small. 
Pus   plugs    seen   with 
microscope.    Epitheli- 
um from  pelvis. 

Reaction    usually   acid, 
may  be  alkaline  if  cys- 
titis complicates. 

Urine  may  contain  more 
albumin  than  pus  ac- 
counts  for.     (Not   in- 
variable.) 

24    hours'    urine    de- 
creased in  acute  cases, 
greatly     increased     in 
chronic. 

o 
c  t^ 

0    V 

•r  c 

S3 

o, 

Q. 

3 

Marked   chills,  emacia- 
tion,   gastric    disturb- 
ances.  If  uremia  pres- 
ent, it  is  of  a  typhoid 
kind,  with  dry  tongue 
and  feeble  pulse. 

Pus  sediment  like  that  of 
pyelitis,  if  urine  acid; 
hyaline   and    granular 
cast  possibly  found.    If 
urine     alkaline,     sedi- 
ment like  that  of  cys- 
titis.   Epithelium  from 
kidney  (small  round) 

u 

4) 

.2 

'tj 

03 

*     . 
3   ^ 

tj  2 

1 
Urine  may  contain  more 
albumin  than  pus  ac- 
counts  for.     (Not   in- 
variable.) 

24     hours'    urine    de- 
creased in  acute  cases, 
greatly     increased     in 
chronic. 

HEMOGL  OB  IN  URIA .  453 

HEMATURIA:   MISCELLANEOUS   NOTES. 

Oliver  reports  a  case  in  which  a  girl  of  eleven,  who  had  been 
exposed  to  possible  infection  from  her  brother  ill  with  typhoid, 
was  taken  severely  ill  and  for  thirty-five  days  had  hematuria, 
together  with  high  temperature.  Blood  disappeared  from  the 
urine  on  the  fall  of  the  fever. 

Sanford  reports  a  case  of  possible  malarial  hematuria  in  a 
new-born  infant,  whose  mother,  a  few  days  before  confinement, 
had  been  treated  for  a  mild  attack  of  malarial  fever.  Hema- 
turia continued  for  four  days,  disappearing  with  the  temperature. 

Moyer  reports  a  case  occurring  in  a  child  of  five  days  with- 
out any  appreciable  cause.  On  the  fifth  day  a  slight  icterus 
set  in,  unassociated  with  any  disturbance  of  health  ;  it  disap- 
peared in  several  days,  the  urine  cleared  up,  and  the  child 
rapidly  recovered. 

Chevalier  reports  a  case  in  a  boy  of  eight  years  whose  mother 
lived  in  Mauritius,  where  hematuria  is  endemic.  Recovery 
took  place  after  prolonged  treatment. 

HEMOGLOBINURIA. 

Sanders,  of  Munich,  reports  a  case  in  a  child  three  days  old  ; 
etiology  uncertain.  It  was  healthy  up  to  the  morning  of  the 
fourth  day,  when  it  became  jaundiced,  the  urine  highly  stained, 
and  death  took  place  in  a  few  hours. 

Ballets  reports  a  case  of  paroxysmal  hemoglobinuria,  in  the 
course  of  severe  jaundice  in  a  child  of  eleven,  pointing  toward 
the  hemoglobinemic  theory  as  possibly  caused  in  this  case  by 
a  species  of  auto-intoxication. 

Day  reports  a  case  of  hemoglobinuria  in  a  child,  following  a 
primary  malarial  paroxysm  of  the  day  previous.  The  stomach 
being  ujiable  to  retain  quinin,  the  drug  was  pushed  by  the 
rectum  with  success. 

Hemoglobinuria  may  possibly  result  from  infection  ;  a  child 
of  two  after  ritual  circumcision  developed  hemoglobinuria, 
became  jaundiced,  etc.,  and  died. 

Dr.  Charles  Heitzmann  of  New  York  demonstrated  to  the 
writer  a  case  of  hemoglobinuria  dependent  upon  creosote  poi- 
soning. When  the  urine  was  fresh  the  odor  of  creosote  could  be 
made  out,  but  after  exposure  to  the  air  for  a  few  hours  the  odor 
was  not  perceptible.  The  case  occurred  in  an  adult,  but  there 
is  reason  to  suppose  that  it  might  occur  in  the  case  of  children. 

If,  in  addition  to  pyuria  or  hematuria,  a  tumor  can  be  made 
out,  consult  the  table  on  page  454.* 


•  Ibid.  Table  XHI. 


454 


THB  DISEASES  OF  CHILDREN. 


01 

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When   very    large, 
blood  and  blood  casts 
in  urine. 

c 
o 

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3  J*! 
O    O 

O    01 

cS  X) 
to 

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E 

L. 

4^ 
C 

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£    3 
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Great  constitutional 
disturbances ;  contin- 
u  0  u  8    elevation     of 
temperature.     Mark- 
ed rigors  and  sweat. 

.2 
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DIFFEREN  TIA  L  DIA  GNOSIS. 


455 


If  no  tumor  can  be  made  out,  and  there  is  suspicion  that  the 
pelvis  of  the  kidney  is  involved,  study  the  following  :* 

DIFFERENTIAL  DIAGNOSIS   IN   TUBERCULAR  PYELITIS,  CALCU- 
LOUS  PYELITIS,  AND  RENAL  CANCER. 


Tuberculous  Pyelitis. 

Calculous  Pyelitis. 

Renal  Cancer. 

Pus  in  the  urine  abun- 
dant, early,  and  con- 
tinuous. Great  quan- 
tities    of     vibriones 
and  micrococci. 

Pus   in   the    urine    in 
small    quantities     at 
first,  slowly  increas- 
ing.    Preceded  by 
mucus. 

Little  or  no  pus  or  de- 
bris. 

Hematuria    not    fre- 
quent, slight,  and  in 
night    urine   as    well 
as   day.      Frequently 
absent   for   long   in- 
tervals. 

Occasional   attacks  of 
slight,  sometimes  se- 
vere, hematuria  after 
exercise,    none     at 
night,    or    after    re- 
pose. 

Hematuria  usually  light 
at  first,  but  later  pro- 
fuse.  Spontaneous, 
continuous,  aggravat- 
ed at  intervals ;  and 
both  after  repose  and 
exercise.  Hematuria 
may  be  absent  in  chil- 
dren. 

Pain: — Greatest    in 
the  bladder,  relieved 
when  the  bladder  is 
empty. 

Pain:  —  Paroxysmal 
and  radiating.  Worse 
on  motion. 

Pain  not  aflfected  by 
movements. 

Pyrexia,  marked. 

Pyrexia  not  marked. 

Pyrexia  not  marked. 

Emaciation,  loss  of  ap- 
petite, etc. 

General      nutrition 
good. 

Loss  of  flesh,  anemia, 
cachexia. 

*Ibid.  Table  XIV, 


CHAPTER  V. 

CANCER  IN  THE  URINARY  TRACT. 

Cancer  of  the  Prostate. — Primary  cancer  of  the  prostate  oc- 
curs chiefly  in  boys  under  ten  and  men  over  fifty.  Engelbach 
found  three  cases  in  boys  less  than  one  year  old.  About  seven- 
eighths  of  the  tumors  are  carcinoma,  the  remainder  sarcoma. 
In  children  the  fatal  termination  is  reached  in  a  short  time,  in 
a  few  months  at  most.  The  most  important  diagnostic  points^ 
according  to  Belfield  are:  (i)  Progessive  emaciation  and 
pallor;  (2)  Hard  enlargement  of  lymph-glands  in  the  groins, 
within  the  pelvis  (detected  by  bimanual  examination),  and  in 
Scarpa's  triangle ;  (3)  irregular,  nodular  enlargement  of  the 
prostate.  If  recognizable  cancer  tissue  can  be  found  in  the 
urine,  the  evidence  is  complete. 

The  treatment  should  be  directed  to  relief  pain,  cystitis, 
urinary  retention,  and  rectal  disturbance. 

Tumors  of  the  Bladder. — The  bladder  tumors  most  common 
in  childhood  are  of  the  polypous  form  (myxoma).  Out  of 
eighty-nine  cases  of  papilloma  of  the  bladder,  collected  by  Dr. 
F.  S.  Watson,  only  one  case  occurred  in  males  between  ten 
and  twenty  years  of  age,  and  one  case  (female)  between  one 
and  two  years  of  age.  In  100  cases  of  cancer  of  the  bladder,  the 
youngest  patient  was  thirty  years  of  age.  Of  sarcoma  of  the 
bladder,  in  twenty  cases  five  were  under  twenty  years  of  age. 

As  to  results  of  operation,  Watson  chronicles  that  in  the 
case  of  two  female  children,  each  two  years  old,  removal  of 
benign  growth  (papilloma)  resulted  in  death  in  both  cases  from 
exhaustion:  one  in  six  months,  the  other  in  sixteen. 

Renal  Cancer. — Primary  cancer  of  the  kidney  is  said  to  be 
more  frequent  during  childhood  than  in  adult  life.  Whenever, 
therefore,  an  abdominal  distention  is  found  in  a  child,  cancer  of 
the  kidney  should  not  be  forgotten.  Renal  cancer  grows 
rapidly,  more  so  than  cancer  in  any  other  part  of  the  body.  It 
is  more  common  in  males.  Out  of  123  cases  of  primary  cancer 
of  the  kidney,  45  occurred  in  children  under  ten. 

Hematuria  is  more  frequently  absent  in  children  than  in 
adults. 

Enlarged  masses  of  lymphatics  in  young  children  may  be 
mistaken  for  renal  cancer ;  but  the  latter  is  almost  invariably 
(456; 


CANCER  IN  THE   URINART  TRACT.     -  457 

unilateral,  while  enlarged  lymphatics  are  usually  to  be  found 
on  both  sides  of  the  abdomen. 

Encephaloid  cancer  is  by  far  the  most  frequent  form  ;  some- 
times tumors  of  a  mixed  character,  weighing  25  or  30  lbs.,  have 
been  met  with  even  in  young  children. 

Children  under  five  are  especially  liable  to  renal  cancer ;  22 
out  of  67  cases  occurred  at  this  period,  and  three  others  between 
seven  and  ten.  Of  the  25  cases  mentioned  two  were  one  year 
old  or  less,  six  between  one  and  two,  six  between  two  and  three, 
eight  between  three  and  five,  two  between  seven  and  eight,  and 
one  ten  years  old.  Of  24  cases  15  were  boys,  and  9  girls. 
The  etiology  is  obscure  ;  blows  or  falls  are  probably  exciting 
causes  only. 

Roberts  cites  a  case  typical  of  infantile  renal  cancer  in  a  boy 
six  months  old.  When  born,  the  nurse  thought  he  had  a  full 
stomach.  A  fortnight  old  he  had  severe  pain  and  flatulency, 
but  was  pretty  well  after  it  until  three  months  old,  when  it  was 
observed  that  his  abdomen  was  larger  than  it  ought  to  be,  and 
it  continued  to  enlarge.  Early  in  life  he  had  had  frequent  at- 
tacks of  diarrhea,  stools  like  "  boiled  moist  cabbage  ;"  later, 
would  go  four  or  five  days  without  evacuation,  the  motions  be- 
ing dry,  hard,  and  yellow.  Up  to  death  he  voided  urine  freely, 
and  the  latter  was  clear  and  free  from  blood.  Appetite  raven- 
ous, and  thirst  intense.  Ten  weeks  before  death  he  was  much 
emaciated,  and  the  abdomen  measured  21  inches  over  the 
umbilicus,  with  universal  dullness  on  percussion,  except  in  the 
left  hypochondriac  and  hypogastric  regions.  The  abdomen  in- 
creased in  size  three  inches  in  two  months.  The  child  died  when 
seven  and  one-half  months  old.  Hounsell  gave  Roberts  notes 
of  a  case  in  a  male  child  of  four  years.  The  boy  had  a  large 
tumor  in  the  umbilical,  right  hypochondriac,  and  lumbar 
regions.  Its  surface  was  dull  on  percussion,  and  the  dullness 
was  continuous  with  that  of  the  liver.  The  child  was  sallow 
and  emaciated.  The  tumor  had  been  detected  three  months 
before  death,  and  had  grown  rapidly.  Hematuria  had  been 
noticed  shortly  before  the  discovery  of  the  tumor,  which  in- 
volved the  right  kidney,  and  weighed  nearly  eleven  pounds. 

Sarcoma  of  the  Kidney. — Dr.  Charles  Heitzmann,  of  New 
York,  recently  demonstrated  to  the  writer,  the  diagnosis  of 
small,  round-celled  sarcoma  of  one  kidney,  by  means  of  micro- 
scopical examination  of  the  urine.  The  patient  was  a  child  of 
six,  and  the  diagnosis  was  confirmed  hy post-mortem.  The  urine 
contained  the  sarcoma  corpuscles,  which  are  midway  in  size 
between  red-blood  corpuscles  and  pus  corpuscles ;  in  addition 
to  sarcoma  corpuscles,  the  urine  contained  shreds  of  fibrous  con- 
nective tissue,  large  bunches  of  it  being  abundant.     The  points 


458  THE  DISEASES  OF  CHILDREN. 

in  the  diagnosis  were,  first,  the  sarcoma  corpuscles,  and  second, 
the  abundant  connective  tissue  shreds.  The  locality  of  the 
tumor  was  decided  by  the  relative  abundance  of  epithelium 
from  the  convoluted  tubules  of  the  kidney.  Uric  acid  crystals 
being  present  showed  involvement  of  one  kidney  only. 

The  diagnosis  of  sarcoma  microscopically  by  the  urine  is  not 
possible  unless  ulceration  of  the  tumor  be  present,  which  in- 
volves the  presence  both  of  red-blood  corpuscles  and  shreds  of 
connective  tissue. 

Sarcoma  corpuscles  are  more  granular  than  blood,  and  are 
without  nucleus,  or  else  are  homogeneous. 

Sarcoma  of  the  kidney  is  more  common  in  children  than  in 
adults,  and  is  sometimes  congenital.  The  symptoms  are  about 
the  same  as  carcinoma,  namely:  rapidly  growing  tumor  in  the 
region  of  the  kidneys,  with  recurring  attacks  of  hematuria. 
In  sarcoma  there  is  probably  less  pain  and  more  hemorrhage 
than  in  carcinoma.  Twelve  cases  of  sarcoma,  in  which  striated 
muscular  fibers  were  found,  are  recorded  by  Roberts,  always 
in  young  children. 

Prognosis  and  Treatment. — The  prognosis  is  unfavorable  and 
treatment  wholly  palliative.  Nephrectomy  is  excluded  in  the 
case  of  children,  as  attention  is  not  usually  called  to  the  dis- 
ease until  recognition  of  an  abdominal  tumor,  removal  of  which 
does  not  remove  the  disease. 

In  the  American  Practitioner  a- id  News  is  an  account  of  sup- 
posed sarcoma  of  the  kidney,  in  a  girl  three  years  and  ten 
months  of  age.  She  had  been  under  observation  but  a  short 
time  and  the  history  was  uncertain.  There  were  no  symptoms 
referable  to  the  growth,  and  as  yet  no  impairment  of  nutrition. 
A  large,  firm  mass  could  be  felt  in  the  left  side  of  the  abdomen 
just  below  the  line  of  the  umbilicus,  and  could  be  distinctly 
seen  when  the  child  was  upon  the  back.  Posteriorly  it  could 
be  detected  in  the  lumbar  region,  and  upon  making  pressure 
forward  the  whole  mass  could  be  felt  to  move  freely. 

It  was  slightly  nodular  and  hard  and  tense  to  the  feel.  It 
seemed  to  cause  no  discomfort  or  pain,  and  was  not  sensitive  to 
pressure.  The  urine  contained  a  few  blood  cells  and  broken, 
granular  and  hyalin  casts.  It  was  beyond  doubt  a  kidney 
tumor,  possibly  a  carcinoma.  Carcinoma  is,  however,  rare  at 
this  age,  while  sarcoma,  if  not  common,  is  the  most  frequent 
kidney  growth. 

At  the  New  York  Pathological  Society,  Dr.  L.  Emmett  Holt 
showed  a  specimen  from  a  patient  two  years  of  age.  A  tumor 
had  been  discovered  in  the  right  side  five  months  before. 
There  was  but  little  impairment  of  nutrition  and  no  definite 
symptoms.     A  diagnosis  of  sarcoma  had  been  made  and  con- 


NOTES  ON  TUBERCULOSIS.  459 

firmed  by  operation.  The  growth  weighed  two  and  a  quarter 
pounds,  and  was  removed  by  lumbar  incision.  One  week  after 
the  operation  the  patient  was  doing  well. 

But  one  result  could  be  expected  in  the  first  case  without 
operation.  The  mass  would  increase  in'  size  and  the  child 
would  waste  and  die. 

HYDRONEPHROSIS. 

Dumreicher,  of  Vienna,  has  reported  a  case  of  hydrone- 
phrosis in  a  girl  of  thirteen,  the  swelling  in  the  abdomen  dating 
from  the  tenth  year.  The  tumor  grew  to  enormous  size,  and 
to  relieve  dyspnea  puncture  was  made  and  i8  quarts  of  a  col- 
loidal, brown-colored  fluid  removed. 

In  13  out  of  20  congenital  cases  mentioned  by  Roberts,  the 
hydronephrosis  was  double.  Two  of  these  perished  still-born, 
one  lived  six  hours,  one  thirty,  one  thirty-six,  while  one  died  in 
twenty  days,  and  another  between  three  and  four  months  after 
birth.  One  case  mentioned  hy  Hare  lived  thirty-eight  years, 
and  four  other  cases  mentioned  by  Roberts  lived  from  five  and 
a  half  to  twenty  years. 

Imperforate  urethra  is  a  cause  of  hydronephrosis  in  children  ; 
phimosis  also.  Congenital  hydronephrosis  is  often  associated 
with  malformations  of  organs,  as  imperforate  anus,  harelip, 
club-foot,  etc. 

NOTES   ON   TUBERCULOSIS. 

Among  315  tuberculosis  children,  RilHet  and  Barthez  found 
tubercle  of  the  kidneys  49  times,  or  15.7  per  cent.  From  this 
it  follows  that  the  kidney  is  nearly  three  times  more  liable  to 
deposits  in  tuberculosis  children  than  in  tuberculosis  adults. 

Renal  tuberculosis  may  occur  as  young  as  three  and  a  half 
years.  Dillreth  mentions  four  cases  out  of  a  total  of  31, 
which  were  between  birth  and  ten  years  of  age,  and  five  cases 
between  ten  and  twenty. 

Acute  miliary  tuberculosis  is  rather  more  frequently  met  in 
children  than  in  adults,  and  the  kidneys  are  less  often  invaded 
than  the  other  organs.  It  usually  invades  both  kidneys  and  is 
found  in  the  cortex  as  miliary  granulomata. 

In  boys  we  sometimes  see  tuberculosis  of  the  vesical  neck 
without  any  discoverable  testicular  involvement,  but  usually 
the  latter  is  present.  Tuberculosis  in  children  does  not  cause 
enuresis,  so  far  as  known.  Dysuria  is  a  symptom  of  tubercu- 
losis of  the  vesical  neck,  but  irritability  of  the  vesical  neck  is 
wanting.     Evidence  of  involvement  of 'the  vesical  neck  is  to  be 


460  THE  DISEASES  OF  CHILDREN. 

found  when  there  is  neither  polyuria  or  dysuria,  by  frequency 
of  urination  or  a  tendency  to  bleed  on  even  the  gentlest  intro- 
duction of  an  instrument. 

If  even  the  fewest  and  smallest  shot-like  nodules  can  be  felt 
in  the  testes,  suspicion  of  tuberculosis  of  the  vesical  neck 
should  be  excited,  and  repeated  examinations  of  the  urine  made 
for  tubercle  bacilli. 

Bryson  has  seen  six  cases  of  tubercular  nodules  in  the  testes 
of  young  children  which  clearly  dated  from  birth.  In  one  case 
of  a  child  of  four,  where  no  testicular  involvement  was  discov- 
erable, a  tubercular  cystitis  was  complicated  by  secondary 
(phosphatic)  calculi, 

SCROFULOUS  KIDNEY. 

At  a  recent  meeting  of  the  Manchester  Pathological  Society, 
Dr.  Railton  showed  specimens  from  a  case  of  scrofulous  kidney 
in  a  boy,  aged  two  years  and  nine  months,  who  had  been  an 
in-patient  at  the  Manchester  Clinical  Hospital.  A  tumor  was 
observed  on  the  left  side  of  the  abdomen,  extending  from  the 
ribs  to  the  iliac  crest,  and  reaching  as  far  forward  as  one  finger's 
breadth  in  front  of  the  vertical  line  of  the  anterior-superior 
iliac  spine.  There  was  no  movement  of  the  tumor  during  res- 
piration, and  the  percussion  note  over  it  was  dull.  There  was, 
in  addition,  some  slight  dullness  over  the  apices  of  both  lungs. 
One  month  after  admission  the  child  died  of  tuberculous 
meningitis.  After  death,  the  left  kidney  was  found  to  be  four 
or  five  times  its  normal  size,  and  almost  completely  transformed 
into  a  caseous  mass  ;  its  pelvis  and  calyces  were  dilated,  and 
contained  purulent  fluid.  The  ureter  was  completely  closed, 
accounting  for  the  fact  that  the  urine  showed  nothing  abnor- 
mal. The  apices  of  both  lungs  showed  infiltration,  caseation, 
calcification,  while  that  of  the  right  showed,  in  addition,  a 
small  cavity.  The  brain  showed  a  considerable  quantity  of 
fluid  in  the  ventricles,  exuded  lymph  in  the  space  between  the 
optic  chiasma  and  pons  and  along  the  sylvian  fissures,  tubercles 
on  the  lower  surface  of  the  lateral  lobes  of  the  cerebellum  and 
in  the  longitudinal  fissure.  Dr.  Railton  remarked  that  the 
disease  in  the  left  kidney  had  probably  existed  for  a  long  time 
before  that  in  the  lungs,  and  had  no  causal  relation  to  it,  and 
that  the  meningeal  tuberculosis  was  of  quite  recent  date.  He 
asked  whether  some  distinction  should  not  be  drawn  be- 
tween a  slow  caseating  process  like  that  in  the  kidney  of  this 
case,  or  as  frequently  witnessed  in  tumors  of  the  cerebellum, 
and  the  rapidly  disseminating  process  known  as  acute  tuber- 
culosis. 


SCROFULOUS  KIDNEY.  461 

Dr.  Dreschfeld  said  that  he  would  have  expected  to  find, 
from  Dr.  Railton's  description  of  the  ante-mortem  appearances, 
the  kidney  much  larger  than  it  turned  out  to  be,  but  had  often 
noticed  similar  discrepancies  in  other  abdominal  tumors.  He 
did  not  consider  that  any  real  difference  existed  between  this 
class  of  case  and  ordinary  tuberculosis.  The  presence  of 
bacilli  in  the  urine  would  be  conclusive  evidence  in  a  similar 
case,  but  in  this  the  blocking  of  the  ureter  rendered  such  ap- 
pearance impossible. 


CHAPTER  VI. 

CALCULUS  IN  THE  URINARY  PASSAGES. 

Etiology  and  Pathology. — In  infancy  and  in  adolescence  oxal- 
ate of  lime  calculus  predominates,  associated  with  carbonate  of 
lime.  Children  of  gouty  parents  are  themselves  subjects  of 
gravel. 

The  deposition  of  clumps  of  urate  of  soda  in  the  urinary  pas- 
sages is  not  uncommon  in  the  febrile  attacks  of  infants  and 
younger  children ;  it  seems  fairly  probable  that  some  of  these 
clumps  may  be  retained,  either  in  the  kidney-pelvis  or  in  the 
bladder,  and  become  the  nuclei  of  future  calculi ;  hence,  per- 
haps, the  excessive  frequency  of  calculi  in  children. 

The  most  frequent  calculus  in  young  children,  then,  is  the 
urate,  mixed  with  uric  acid.  The  color  is  light  fawn  or  grayish- 
yellow.  Infarcts  of  urates  are  found  sometimes  in  the  renal 
tubes  of  young  infants,  and  consist  of  irregular  masses  of  am- 
monium and  sodium  urate,  forming  yellow-red  lines,  radiating 
from  the  papilla  to  the  basis  of  the  pyramids.  They  are  not 
found  in  the  kidneys  of  still-born  children,  but  usually  occur 
from  the  second  to  the  nineteenth  day  after  birth,  and  in  some 
instances,  as  late  as  three  or  four  months.  They  are  generally 
regarded  as  physiological  rather  than  pathological. 

The  frequency  of  stone  in  the  bladder  is  far  the  greatest  un- 
der five  years  of  age,  and  next,  between  ten  and  fifteen. 
Thompson's  statistics  show  that  of  1827  persons,  who  under- 
went lithotomy  in  England,  473  were  under  five  years  and  528 
between  five  and  fifteen. 

Stone  is  said  to  be  more  common  among  the  children  of  the 
poor  than  in  those  of  the  rich. 

Symptoms. — In  young  children,  prolapsus  ani,  priapism,  and 
bloody  urine  are  signs  of  calculus  disease.  If  the  stream  of 
urine  is  abruptly  checked,  suspect  stone  in  the  bladder  or  deep 
urethra.  Retention  of  urine  in  a  child  often  means  a  concretion 
impacted  in  the  urethra.  Examine  the  napkins  in  suspected 
cases  for  reddish-brown  stains,  or  in  older  children,  the  urine, 
for  evidences  of  uricemia,  oxaluria,  or  phosphaturia.  If  the 
calculus  is  deposited  in  the  kidney,  there  will  be  occasional  at- 
tacks of  slight,  sometimes  severe,  hematuria  after  exercise,  but 
little  or  none  at  night  or  after  repose ;  pain  is  worse  on  motion ; 
(462) 


CALCUL US  IN  URINA RT  PA SSA GES.  463 

the  urine  may  contain  pus,  in  small  quantities  at  first,  slowly 
increasing. 

Prog?tosis  and  Treatment.  —  In  uric-acid  calculus  (renal)  the 
prognosis,  as  a  rule,  is  favorable.  The  treatment  consists  of 
copious  drinks,  warm  baths,  non-nitrogenous  diet,  and  crude 
drugs,  as  sodium  phosphate  and  benzoates  in  small  doses. 

If  the  stone  be  in  the  bladder,  and  from  the  sediment  is  evi- 
dently uric  acid  or  urates,  and  not  oxalate  or  unknown,  Roberts 
believes  in  trying  solvent  treatment,  recommending  20  grains 
of  citrate  of  potassium,  in  three  ounces  of  water  every  three 
hours,  raising  it  soon  to  25  grains,  and  after  two  months  to  30 
grains.  He  has  tried  solvent  treatment  successfully  in  three 
cases  of  calculus  of  the  bladder  in  children  from  four  to  twelve 
years  of  age,  and  makes  the  deduction  that  a  continuously  al- 
kaline state  of  the  urine  does  not  determine  any  precipitation 
of  the  earthy  phosphates  on  the  stone,  so  long  as  the  urine  is 
free  from  ammoniacal  decomposition. 

Miscellaneous  Notes. — Hance  has  recorded  the  accidental  dis- 
covery of  an  oxalate-of-lime  calculus  in  the  body  of  an  infant 
aged  twenty  months,  who  had  died  of  pulmonary  tuberculosis 
and  whooping  cough. 

Duret  removed  a  vesical  calculus  weighing  two  ounces  (60 
gm.)  from  the  bladder  of  a  child  of  six  years.  The  stone  was 
the  size  of  a  mandarin,  smooth,  with  a  center  of  brown  sur- 
rounded by  concentric  layers  of  white. 

Langenbeck  removed  a  xanthin  calculus,  size  of  a  small  egg, 
from  a  boy  of  eight. 

Taylor  saw  a  xanthin  stone  weighing  a  quarter  of  an  ounce 
taken  from  a  child  of  four. 

Dulk  removed  a  xanthin  calculus  weighing  seven  grains  from 
the  urethra  of  a  boy. 


CHAPTER  VII. 

URICEMIA. 

Synonyms  and  Definition. — The  synonyms  are  Hthemia,  uric- 
acidemia,  uric-acid  diathesis,  lithic-acid  diathesis,  lithuria.  Dis- 
ease in  which  the  blood  contains  excess  of  uric  acid,  or  in  which 
the  latter,  being  imperfectly  eliminated,  accumulates  in  the 
system. 

Etiology. — Heredity  and  digestive  disorders  are  the  usual 
causes  to  which  uricemia  is  referable.  In  children,  uric  acid, 
gravel  or  calculus,  is  frequently  the  result  of  debilitating  illness, 
and  from  the  very  highly  acid  urine  secreted  by  them  under 
very  slight  disturbing  influence.     (Ralfe.) 

Pathology. — We  do  not  know  how  or  where  uric  acid  is  pro- 
duced in  the  body.  In  some  cases  there  are  deposits  of  uric 
acid  or  urates  in  the  urine,  without  increase  of  total  uric  acid  in 
the  urine,  and  again  the  total  uric  acid  may  be  in  excess  in  the 
urine  without  deposits  of  uric  acid  or  urates.  Haig  thinks 
changes  in  elimination,  rather  than  in  formation,  responsible  for 
the  various  clinical  phenomena. 

Retention,  for  example,  of  uric  acid  in  the  system,  is  respon- 
sible for  certain  pains,  while  large  excretion,  by  increasing 
arterial  tension,  causes  others. 

Symptoms. — According  to  Sutherland  the  symptoms  of  uric- 
emia in  children  are  of  two  classes :  those  due  to  presence  of 
uric  acid  in  the  system,  and  those  due  to  excretion  of  uric  acid 
from  the  system.  Symptoms  due  to  the  presence  of  uric  acid 
in  the  system  are  as  follows :  The  children  have  keen,  precocious 
minds,  small  restless  bodies,  and  are  excitable  and  nervous. 
They  are  bright  and  amusing  at  one  time,  greatly  depressed  at 
another.  They  do  not  readily  fall  asleep  at  night,  often  talk 
in  their  sleep,  wake  early  in  the  morning,  are  dainty  feeders 
and  like  everything  that  is  bad  for  nutrition  ;  are  very  subject 
to  colds,  and  a  chill  in  some  form  or  other  is  the  precursor  of 
an  acute  attack.  They  sweat  profusely  on  moderate  heat  or 
exertion  and  have  cold  hands  and  feet.  The  acute  attacks  are 
usually  short,  especially  if  the  child  is  kept  in  bed,  and  are 
prone  to  recurrence  ;  during  them  the  pharynx  is  relaxed  and 
irritable,  causing  a  loud,  barking  cough  most  marked  when  the 
child  goes  to  bed,  and  possibly  accompanied  by  some  bronchial 
(464) 


URrCEMlA.  465 

inflammation.  The  tonsils  and  adenoid  tissue  of  the  naso- 
pharynx are  liable  to  acute  attacks  leading  to  chronic  thicken- 
ing and  enlargement.  There  is  frontal  headache  and  symptoms 
of  intestinal  catarrh  with  furred  tongue  and  foul  breath. 
Slight  irregularity  of  the  heart  occurs  usually  and  the  pulse  is 
often  small,  weak,  and  irregular.  The  liver  and  spleen  ma,y  be 
enlarged.  In  some  cases  abdominal  pain  is  the  only  complaint, 
and  this  is  sometimes  found  to  be  localized  in  the  right  iliac 
fossa. 

The  symptoms  due  to  excretion  of  uric  acid  from  the  system 
are  the  following :  Pain  is  prominent ;  renal  colic  may  occur 
and  pass  for  "  stomach-ache."  The  pain  may  be  present  in 
any  part  of  the  urinary  tract  from  the  kidney  downwards,  is 
intermittent  in  character,  and  often  so  intense  as  to  cause  the 
child  to  cry  out,  especially  in  the  middle  of  the  night.  Renal 
hematuria  is  frequently  the  first  symptom  and  there  may  be 
more  or  less  shivering,  nausea,  and  sickness  present  during  an 
attack.  The  pain  is  supra-pubic  if  the  bladder  is  affected,  and 
extends  along  the  urethra  to  the  meatus.  The  pain  is  often 
brought  on  by  walking,  and  is  increased  during  micturition,  so 
that  the  urine  is  retained  for  a  considerable  period.  Henoch, 
according  to  Sutherland,  describes  a  case  of  convulsions,  in  a 
child  five  months  old,  due  to  reflex  irritation  from  extreme 
dysuria,  accompanied  by  passage  of  large  uric  acid  crystals. 

As  the  kidneys  are  believed  to  secrete  the  uric  acid  from  the 
blood,  it  is  probable  that  great  irritation  may  be  caused  in  the 
tubules  by  the  mechanical  contact  with  the  sharp  particles. 
These  may  soon  combine  with  the  bases  in  the  urine,  are  thus 
rendered  non-irritant,  and  may  be  excreted  without  producing 
any  disturbance  in  the  urinary  tract.  Should  the  urine,  how- 
ever, contain  only  a  small  amount  of  these  bases,  or  should  the 
passage  of  the  uric  acid  through  the  tubules  be  hastened,  pain 
will  probably  be  present,  and  this  is  what  we  find,  for  ex- 
ample, in  the  screaming  at  night,  when  the  urine  is  most 
acid,  and  in  the  pain  caused  by  walking,  when  both  from  the 
vascular  and  muscular  pressure,  the  kidneys  are  emptied  of 
their  contents  more  rapidly. 

The  greater  the  proportion  of  solid  to  fluid  constituents  of 
the  urine,  the  more  marked  will  the  pain  be,  while,  if  the 
watery  constituents  are  abundant,  pain  will  probably  be  entirely 
absent.  It  is  a  marked  feature  in  the  subjects  of  this  diathesis 
that  they  drink  in  moderation,  while  they  sweat  profusely  on 
slight  exertion,  with  the  result  that  the  amount  of  urine  passed 
is  small.  Many  cases  of  intractable  incontinuence  are  due  to 
inflammation  of  the  bladder,  which  is  induced  and  kept  up  by 
the  excessive  acidity  of  the  urine.  Rectal  pain,  incontinuence 
D.  C— 30 


466  THE  DISEASES  OF  CHILDREN. 

of  the  feces,  pain  during  defecation,  prolapse  of  the  rectum^ 
and  irregularity  of  the  bowels  will  often  be  cured  by  directing 
the  treatment  solely  to  the  condition  of  the  bladder  and  urine. 
This  may  be  confirmed  on  rectal  examination  by  the  tender- 
ness which  is  found  on  pressing  forwards  over  the  lower  part 
of  the  bladder.  Albuminuria  is  not  infrequent,  with  or  with- 
out hematuria,  and  is  produced,  like  the  latter,  by  mechanical 
irritation  in  the  kidneys.  The  amount  of  albumin  may  vary 
from  the  merest  trace  up  to  one-half  (on  boiling),  and  tube 
casts  may  be  present,  usually  fewer  in  number  and  of  a  more 
limited  variety  than  in  albuminuria  from  organic  structural 
disease  of  the  kidneys.  A  catarrhal  inflammation  in  the  pelvis 
of  the  kidney,  or  about  the  neck  of  the  bladder,  is  manifested 
by  the  appearance  of  pus  cells  and  epithelial  scales  in  the 
urine.  Dr.  Milner  Fothergill  says  that,  "A  large  deposit  of 
urates  is  a  storm  signal,"  and  these  storm  signals  are  of  great 
use  in  this  latent  disease.  In  a  case  of  that  of  a  little  girl, 
aged  ten  years,  who  was  apparently  in  good  health,  but  whose 
urine  contained  urates  and  uric  acid  in  such  abundance  as  to 
attract  special  attention.  This  was  soon  followed  by  an  at- 
tack of  tonsilitis,  pericarditis  with  delirium,  endocarditis,  and 
very  severe  chorea.  Most  of  the  above  symptoms  are  illus- 
trated in  the  accompanying  cases.  There  are  some  others  in 
which  the  connection  with  uric  acid  may  not  be  so  readily 
admitted.* 

Inasmuch  as  children  in  twenty-four  hours  excrete  more  uric 
acid  per  pound  of  weight  than  adults,  they  are  thus  by  nature 
placed,  as  Haig  observes,  much  in  the  position  of  an  adult  who 
eats  largely  of  meat,  hence  are  liable  to  uric-acidemia.  The 
symptoms  are  gastro-intestinal  disturbance,  loss  of  appetite, 
headache,  and  slow  pulse. 

Children  fed  on  meat  and  meat  extracts,  often  suffer  from 
gastro-intestinal  derangements,  skin  diseases,  and  early  mi- 
graine ;  in  these  patients  rheumatism  and  its  most  serious  man- 
ifestations should  be  expected  early.  Haig  mentions  a  case  of 
hemoglobinuria,  in  which  a  child,  aged  fouryears  and  ten  months, 
was  subject  to  attacks  of  cold  and  shivering,  during  which  he 
passed  high-colored  urine.  Before  each  attack  he  felt  more  than 
usually  well,  but  his  bowels  were  constipated  ;  just  before  the 
attack  he  yawned  a  great  deal,  his  pulse  was  slow,  and  he  com- 
plained of  headache.  Haig  thinks,  in  this  case,  that  the  blood 
in  the  urine  was  due  to  a  uric  acid  storm. 

In  general,  when  children  present  a  number  of  vague  and 
anomalous  symptoms,  uricemia  may  be  suspected  and  the  urine 


•  Southerland,  British  Med.  Journal.,  1892. 


URICEMIA—  TREA  TMEN T.  467 

should  be  examined.  According  to  some  authorities,  30  per 
cent,  of  all  children,  and  especially  those  at  school,  have  neu- 
rasthenia, and  other  incomplete  expressions  of  defective  meta- 
bolic action. 

In  cases  of  colic,  examine  the  napkins  of  young  children  for 
reddish-brown  stains,  and  look  for  prolapsus  ani,  priapism,  and 
bloody  urine  as  signs  of  calculous  disease.  If  the  stream  of 
urine  is  abruptly  checked,  suspect  stone  in  the  bladder  or  deep 
urethra.  Retention  of  urine  in  a  child  often  means  a  concre- 
tion impacted  in  the  urethra. 

The  Urine  in  Uricemia. — The  urine  may  be  clear  when 
voided,  but  soon  becomes  thick  and  opaque,  or  covered  with  a 
delicate  film  or  pellicle,  exhibiting  faintly  a  play  of  prismatic 
colors  ;  or  in  a  few  hours  their  is  seen  in  the  sediment  a  deposit 
of  free  uric  acid—"  red  pepper  "  crystals.  The  chamber  vessel 
in  such  cases  becomes  covered  with  a  slimy  pinkish  coating,  dif- 
ficult to  remove. 

In  some  cases  the  above  condition  may  be  absent ;  if  quanti- 
tative analysis  of  the  urine  shows  deficient  elimination  of  uric 
acid,  especially  if  there  is  increase  in  the  urea-uric  acid  ratio, 
while  at  the  same  time  the  symptoms  described  above  as  due 
to  uric  acid  in  the  system  are  present,  the  condition  may  yet 
be  one  of  uricemia. 

What  the  normal  urea-uric  acid  ratio  may  be  is  difficult  to 
determine,  as  we  yet  have  no  method  for  the  quantitative  esti- 
mation of  uric  acid  which  is  not  open  to  criticism.  Haig,  using 
Haycraft's  method,  asserts  that  it  is  33  to  i;  Yvon-Berlioz  put 
it  at  40  to  I  ;  Parkes  at  60  to  i;  Olof  Hammarsten  from  50  to 
I,  to  70  to  I.  In  new-born  infants,  and  in  the  first  days  of 
life.  Mares  puts  it  at  about  13-14  to  i. 

Treatment. — Speaking  of  the  treatment  of  uricemia  head- 
ache, E.  C.  Seguin  makes  the  following  sensible  suggestions  ; 
which  apply  to  uricemia  in  general. 

"  The  diet  should  consist  of  a  minimum  of  sweet  and  starchy 
foods,  a  moderate  amount  of  meat,  an  abundance  of  green 
vegetables,  milk,  eggs,  poultry,  and  fish.  There  should  be 
regular  exercise  in  addition  to  play.  Cold  baths  or  sponges 
may  be  taken.  The  patient  is  to  have  plenty  of  sleep  and 
plenty  of  water,  especially  at  meals,  as,  for  example,  the  mild 
lithia  waters." 

In  my  opinion,  this  is  the  best  general  regime  for  uricemia 
which  has  been  published.  I  lay  especial  stress  on  the  im- 
portance of  allowing  the  uricemic  child  plenty  of  sleep.  For 
some  reason  not  altogether  plain,  sleep  is  apparently  one  of 
the  best  "  antidotes  "  to  the  uric  acid  poison  which  there  is. 
Rousing  a  uricemic  patient  before  he  has  completed  his  full 


468  THE  DISEASES  OF  CHILDREN. 

quota  of  sleep  is  an  act  of  cruelty.  The  worst  cases  of  uric- 
emia  are  those  in  which  insomnia  is  established,  for  sleep,  and 
plenty  of  it,  is  the  great  desideratum  in  treatment. 

Copious  drinks,  and  in  some  cases  warm  baths,  are  advisable. 
There  are,  however,  some  uricemic  children  who  do  not  take 
kindly  to  too  frequent  baths  of  any  kind,  and  become  wakeful 
and  restless  if  the  latter  be  taken  at  night. 

Remedies. — In  the  case  of  children  the  leading  remedies  are 
nux  vomica,  calcarea  carbonica,  and  lycopodium,  Bryonia,  podo- 
phyllum, arsenicum,  belladonna,  cantharis  are  also  needed  at 
times.  If  the  case  is  one  of  gravel  or  calculus,  berberis,  uva 
ursi,  etc. 

When  the  urine  is  deficient  in  water,  the  solids  being  rela- 
tively in  excess,  color  high,  red  sandy  sediment  of  uric  acid  and 
urates,  or  whitish  sediment  of  urates  mixed  with  pus  and 
mucus,  possibly  even  blood,  together  with  dull  pains  in  the 
kidney,  relieved  by  voiding  urine,  lycopodium  is  the  remedy  ;* 
nux  vomica  when  disturbances  of  digestion  are  the  root  of  the 
evil,  and  calcarea  carbonica  in  typical  subjects.  In  one  case 
nux  vomica  3x,  alternated  with  calc.  carb.  6x,  "gave  marked 
benefit  in  a  short  time. 

If  there  is  much  blood  in  the  urine  thlaspi  should  be  tried 
(tincture,  15  to  30  drop  doses). 

As  to  the  use  of  lithia  waters,  the  following  may  be  said :  In 
some  cases  while  they  diminish  alkalinity  temporarily,  the 
urine  may  become  later  more  acid  than  ever.  In  which  case 
copious  draughts  of  pure  spring  water  are  better. 

The  following  case  of  uricemia  has  come  under  the  writer's 
treatment :  Girl,  four  years  of  age,  light  complexion,  restless, 
nervous ;  is  somewhat  puffy  under  the  eyes,  much  irritation  of 
genitals  with  prolapse  of  labial  folds,  brick-dust  sediment  in 
the  urine;  urine  scanty,  urea  13^  grains  to  the  ounce  (28 
grams  per  liter),  phosphoric  acid  i  grain  to  the  ounce  (2.3 
grams  per  liter),  albumin  faint  trace,  acidity  increased,  sedi- 
ment contains  urates  and  uric  acid.  Lithium  benzoate,  third 
decimal  trituration,  was  given  four  times  daily  with  benefit. 
Removal  to  the  fresh  air  of  the  country  restored  patient  to 
health.  After  returning  to  the  city  the  urine  after  a  time  be- 
gan to  show  much  uric  acid  again  on  the  advent  of  digestive 
disturbances.  Nux  3X  and  calc.  carb.  6x  were  then  given  and 
with  beneficial  results. 

Miscellaneous  Notes. — Haig  saw  a  case  of  splenic  leucocy- 
themia  in  a  boy,  aged  ten.  Examination  of  the  urine  revealed 
the  ratio  of  uric  acid  to  urea  to  be  i  to  13.8  instead  of  i  to  33, 


*  H.  N.  Lyon,  Medical  Visitor,  1890. 


URICEMTA.  469 

the  normal.  The  child  was  put  on  a  mixture  containing 
dilute  nitro-hydrochloric  acid  three  times  a  day  before  meals 
and  another  mixture  containing  salicylate  of  sodium  gr.  x  and 
Sp.  Am.  Arom.  m.  xv  three  times  a  day  after  meals,  with  im- 
mediate improvement  and  rapid  recovery. 

In  two  cases  of  Raynaud's  disease  in  children,  Haig  found 
the  ratio  of  uric  acid  to  urea  to  be  enormous,  sometimes  as  high 
as  I  to  8.3.  Under  nitro-glycerin  the  patients  improved  and 
the  uric-acid  urea  ratio  fell  to  as  low  as  i  to  53  in  one  case. 

In  the  case  of  children  of  markedly  gouty  and  rheumatic 
families,  or  of  those  in  whose  families  bilious  attacks,  head- 
aches, or  epilepsy  are  prominent,  Haig  thinks  a  decided  reduc- 
tion of  the  animal  nitrogen  in  their  food  is  strongly  indicated 
as  a  prophylactic  measure. 

Seguin  recommends  dilute  nitro-muriatic  acid,  3  to  10  drops 
in  a  tumbler  of  water  after  meals.  Strong  alkalies  or  lemon 
juice,  if  used,  should  be  given  three  or  four  hours  after  meals. 


CHAPTER  VIII. 

DIABETES  MELLITUS. 

Definition. — Diabetes  mellitus  is  a  disease  characterized  by 
persistent  presence  of  sugar  in  the  urine,  together  with  polyuria. 

Etiology. — Heredity  and  especially  a  phthisical  history.  Next 
to  heredity,  previously  existing  diseases,  notably  gastric  ca- 
tarrh. Diabetes  mellitus  in  children  has  been  known  to  follow 
typhoid  fever  and  purpura  hemorrhagica.  Over-exertion,  pro- 
fuse perspiration,  and  cold  are  said  to  have  caused  at  least  one 
case  ;  falls  and  blows  on  the  head  are  etiological  factors  ;  also 
daily  exposure  to  wet  and  cold,  and  cold  baths. 

Transient  glycosuria  in  children  has  succeeded  malarial  dis- 
ease, measles,  immoderate  eating  of  saccharine  matters  and 
even  fatty  substances,  as  well  as  indiscriminate  eating,  with 
daily  exposure  to  wet  and  cold.     (Stern.) 

Dr.  John  A.  Larrabee  thinks  it  can  be  shown  that  diabetes 
is  connected  with  inherited  neurotic  tendencies.  Epileptic,  and 
nervous,  hysterical  parents  often  leave  this  legacy  to  their  chil- 
dren. In  his  opinion,  the/bwi'  et  origo  ntali  is  a  changed  polar- 
ity of  the  nervous  system  in  the  medulla,  without  observable 
lesion. 

Schn^e  thinks  diabetes  intimately  connected  with  syphilis  ; 
he  speaks  of  making  the  following  "  discovery  :"  "  Diabetes  is 
an  hereditary,  constitutional  disease ;  and  the  etiological  ele- 
ment of  this  disease  is  lues  contracted  by  some  ancestor." 

Kiihl's  observations  on  diabetes  in  children  are  that  the  in- 
fluence of  heredity  is  as  follows :  parents  of  diabetic  children 
either  have  diabetes  or  some  nervous  malady.  He  regards 
traumatism  as  one  of  the  causes.  He  finds  that  mild  cases 
may  become  severe  more  quickly  under  the  influence  of  trau- 
matism. 

Loomis  mentions  a  case  in  a  female  child  twelve  years  of  age, 
who,  after  fourteen  months'  illness  from  Bright's  disease,  eigh- 
teen months  subsequent  to  scarlet  fever,  suddenly  died  of 
diabetic  coma. 

Age. — Out  of  117  cases  in  children,  Stern  found  6  under  one 

year  of  age,  i  seemingly  born  with  it ;  7  over  one  year ;  3  over 

two  years ;  7  over  three  years  ;  6  over  four  years ;  5  over  five 

years  ;  i  over  six  years  ;  6  over  seven  years  ;  two  had  completed 

(470) 


DIABETES  MELLITUS.  471 

€ight  years  ;  8  were  nine  years  old  ;  6  were  ten  ;  9  were  eleven  ;  8 
were  twelve  ;  9  were  thirteen  ;  5  were  fourteen ;  4  were  fifteen  ; 
28,  age  not  given.  They  were  all  of  the  better  class  and  only 
one  Jewish. 

Out  of  618  cases  of  all  ages,  W.  J.  Scott  found  only  4  under 
ten  years.     One  was  fourteen  months. 

Out  of  140  diabetic  cases  of  all  ages,  Seegen  found  none  be- 
tween the  ages  of  one  and  ten,  and  but  5  between  eleven  and 
twenty. 

Out  of  380  cases  of  all  ages,  Mayer  found  but  i  case  under 
ten  years  of  age,  and  4  between  ten  and  twenty. 

Nagle,  quoted  by  Fowler,  reports  4  deaths  from  diabetes 
mellitus  in  children  under  five  years,  in  the  years  1878  to  1887 
inclusive,  in  New  York  City,  population  1,400,000;  29  deaths 
between  five  and  twenty  years. 

Prout,  out  of  700  cases,  saw  only  one  in  a  child  of  five,  and 
about  a  dozen  between  eight  and  twenty  years. 

According  to  Roberts,  diabetes  is  rare  under  five  years  of  age. 
In  the  reports  of  the  British  Registrar-general  from  185 1  to 
i860,  ten  deaths  from  diabetes  in  children  under  one  year  of 
age  are  registered  in  England  and  Wales,  with  a  population  of 
19,000,000,  and  32  under  three  years  of  age. 

West  saw  only  one  case  at  three  and  a-half  years. 

Schmitz,  out  of  21 15  cases  of  diabetes,  saw  85  under  twenty 
years  of  age.  Ten  were  from  one  to  ten  years  old,  and  75  were 
from  ten  to  twenty  years  old.  Hereditary  predisposition,  he 
found  in  998  cases,  and  he  has  seen  five,  six,  up  to  eight  or  ten, 
and  even  twelve  cases  in  one  family.  In  some  cases  the  pre- 
disposition was  congenital,  but  not  hereditary,  brothers  or  sisters 
being  diabetic. 

Isenflam  saw  a  family  in  which  eight  children  of  healthy 
parents  all  died  of  diabetes  after  reaching  their  eighth  year. 

Sex. — Female  children  are  more  susceptible  to  the  disease 
than  males.* 

Out  of  78  cases,  Stern  found  47  females  and  31  males. 
Simpson  says  that  the  proportion  of  males  to  females  varies 
distinctly  with  age,  being  about  equal  up  to  ten  years,  and 
from  that  up  it  is  more  frequent  in  the  male. 

Pathology. — No  constant  lesion  has  been  found  which  distin- 
guishes diabetes  mellitus.  Pavy's  idea  is,  that  the  whole  trouble 
is  due  to  imperfect  de-arterialized  venous  blood,  consequent 
upon  vaso-motor  paralysis,  especially  of  the  vessels  of  the 
chylo-poietic  system.  Modern  research  has  shown  that  in  some 
cases  there  is  lesion  of  the  pancreas.     Larrabee's  opinion  is, 

*  Kuhl. 


472  THE  DISEASES  OF  CHILDREN. 

that  there  is  changed  polarity  of  the  nervous  system  in  the 
medulla,  without  observable  lesion. 

Symptoms  afid  Complications. — Diabetes  sometimes  manifests 
itself  in  children  by  wetting  of  the  bed,  and  in  all  children  in 
which  this  symptom  is  noticed  it  is  prudent  to  examine  the 
urine  for  sugar.  In  sucking  babes,  loss  of  flesh  is  sometimes 
the  first  noticeable  symptom. 

The  usual  symptoms  are  persistent  glycosuria,  polyuria, 
polydipsia ;  hunger,  which  may  sometimes  be  ravenous,  and 
emaciation. 

Complications  of  diabetes  are  coma,  albuminuria,  phlegmon- 
ous and  gangrenous  processes,  erysipelas,  pruritus,  eczema, 
disturbances  of  sight,  cystitis,  and  various  other  disorders. 

Fichtner  saw  a  case  in  a  girl  of  ten  years,  among  whose 
symptoms  were  abolition  of  knee-reflex  and  diffuse  retinitis. 
(Acetone  was  found  in  the  urine,  but  not  oxybutyric  acid.) 

According  to  Litten,  sudden  blindness  in  young  diabetics 
sometimes  occurs.  There  is  no  affection  in  which  disturbances 
of  sight  are  so  frequently  met  as  in  diabetes.  All  the  ocular 
tissues,  viz.,  the  cornea,  iris,  crystalline  lens,  vitreous  humor, 
retina,  muscles,  etc.,  may  be  affected,  but  changes  in  the  crys- 
talline lens  are  the  most  common  of  the  ocular  manifestations 
of  diabetes. 

The  causes  of  diabetic  cataract  are  but  little  known.  Ac- 
cording to  Seegen,  it  is  to  be  attributed  to  the  presence  of 
exaggerated  glycosuria  and  diabetic  cachexia,  and  is  always 
bilateral. 

Seegen's  explanation  holds  good  only  in  young  patients  un- 
der twenty  years  of  age,  seeing  that  in  old  people  diabetic 
cataract  is  often  unilateral,  while  it  may  be  associated  with  but 
moderate  glycosuria. 

In  two  cases  under  Litten 's  observation,  cataract  developed 
with  amazing  rapidity,  the  evolution  being  complete  in  the 
space  of  a  few  hours. 

The  first  patient  was  a  girl,  aged  seventeen,  in  a  cachectic 
condition,  excreting  about  twelve  ounces  of  sugar  in  the 
twenty-four  hours.  There  was  complete  loss  of  sight  on  the 
right  and  imperfect  vision  on  the  left  side.  She  was  operated 
on  by  Dr.  Hirschfeld,  the  lens  being  dislocated  in  the  anterior 
chambers,  where  it  was  rapidly  absorbed.  The  patient's  sight 
has  considerably  improved  since. 

The  second  case  was  identical  with  the  one  just  described. 
No  operation  was  performed,  and  the  patient  is  now  absolutely 
blind. 

Death  has  been  known  to  follow  operation  for  double  cata- 
ract in  a  diabetic  child. 


DIABETES  MELLITUS.  473 

Diabetic  Coma. — Coma  is  more  common  in  children  than  in 
adults,  and  sudden  deaths  from  it  have  been  noted.  Early  rec- 
ognition of  diabetic  coma  is  very  difificult  and  in  some  cases 
impossible,  but  it  may  be  said  in  general  that  any  sudden  im- 
provement in  the  condition  of  the  urine  and  objective  symp- 
toms, not  confirmed  by  subjective  sensations  on  the  part  of  the 
patient,  should  put  the  physician  on  his  guard;  reduction,  for 
example,  of  excessive  appetite  to  below  the  standard  for  a 
healthy  child  ;  unexpected  and  unexplained  loose  movements 
when  constipation  had  previously  been  the  rule ;  peculiar  ace- 
tone odor  to  the  breath,  suggesting  a  mixture  of  chloroform 
and  acetic  acid ;  acid  eructations  and  nausea,  with  or  without 
vomiting  ;  general  prostration  and  disinclination  to  exertion  ; 
tendency  to  drowsiness,  even  in  the  daytime,  with  low  spirits 
and  despondency  ;  attacks  of  dizziness,  frontal  headache,  neu- 
ralgic pains,  accelerated  pulse  with  or  without  decrease  in 
volume.  After  a  variable  period  of  indefinite  symptoms  like  the 
above,  the  patient  will  complain  of  a  feeling  of  depression,  is 
restless  at  night,  eats  nothing,  has  colicky  pains,  vomits  matter 
sometimes  having  acetone  odor,  has  sense  of  constriction  about 
the  thorax  causing  deeper  breathing  than  usual  ;  the  mental 
condition  varies  from  excitability  to  mild  talkative  delirium, 
alternating  with  drowsy  or  stupid  intervals. 

Gastro-intestinal  derangements  seem  to  stand  in  causal  rela- 
tion, and  coma  may  follow  any  unusual  strain  on  the  diges- 
tion, as  also  great  fatigue ;  for  instance,  that  of  a  railroad  jour- 
ney. If  a  sudden  onset  of  nervous  symptoms  be  noticed  when 
the  patient  has  been  put  on  diet,  the  latter  should  be  relaxed.* 

The  order  of  symptoms  in  diabetic  coma  is  often  as  follows : 
Dyspnea,  great  excitement  and  wildness,  benumbing  of  the 
senses,  coma. 

Sudden  death  from  diabetic  coma  is  possible  in  cases  like  the 
following :  Sugar  in  the  urine  not  controlled  by  diet  and 
medication  ;  patient  extremely  weak  ;  lower  extremities  edema- 
tous ;  tongue  red,  raw  and  glazed  ;  mouth  and  throat  covered 
with  aphthous  patches ;  uncontrollable  diarrhea;  acute  inflam- 
matory affections  of  the  lungs  present,  or,  earlier  in  the  disease, 
chronic  pneumonia.f 

The  urine  in  diabetic  coma  is  diminished  in  twenty-four 
hours'  quantity,  and  in  amount  of  sugar.  There  is  extreme 
acidity,  and  the  urine  may  have  the  acetone  odor.  Albumin 
in  small  quantity  is  usually  though  not  invariably  found.  The 
so-called  ferric  chloride  reaction  is  sometimes  noticed. :j; 


*  From  Mitchell's  "  Clinical  Studj-  of  Diseases  of  the  Kidney,"  second  edition,  page  380. 
+  Ibid.,  page  379. 
\  Ibid.,  page  3S1. 


474  THE  DISEASES  OF  CHILDREN. 

Cystitis. — This  disorder  may  occur  in  connection  with  dia- 
betes. Teschemacher  records  a  case  of  a  boy  of  eleven  in  which, 
on  the  advent  of  vesical  catarrh,  the  glycosuria  disappeared, 
reappearing  with  the  improvement  in  the  vesical  condition. 

Effect  of  Mental  Excitement. — The  influence  of  mental 
excitement  on  glycosuria  is  shown  by  Teschemacher  in  an  ac- 
count of  a  very  interesting  case.  A  delicate  boy  of  seven, 
hereditarily  predisposed  to  diabetes,  being  attacked  by  this 
malady,  was  put  on  restricted  diet,  when  the  sugar,  which  at 
first  was  4  per  cent.,  fell  to  0.35  per  cent.,  and  subsequently 
disappeared  altogether.  Soon  after  this  he  was  attacked  by  a 
dog,  which  sprang  at  him  and  he  fell  to  the  ground,  where  he 
lay  half  unconscious  with  terror.  He  was  carried  home  and 
put  to  bed.  Trembling  at  first  and  speechless,  he  lay  in  bed 
for  some  hours  before  he  partook  of  food,  while  he  repeatedly 
asked  for  drink.  Next  day  he  was  brought  to  Teschemacher, 
who  examined  the  urine,  and  was  astonished  to  find  3.3  per 
cent,  of  sugar.  According  to  the  mother,  the  quantity  of  urine 
passed  was  increased.  Restricted  diet  was  again  ordered.  On 
the  following  day  the  sugar  stood  at  2.4  per  cent.,  two  days 
later  at  only  1.5  per  cent.,  and  at  the  end  of  eight  days  it  had 
entirely  disappeared.  This  case  furnishes  a  striking  example 
of  the  relapse  of  glycosuria  after  great  mental  excitement. 
Dietetic  errors  were  strongly  denied  by  the  mother,  and  the 
ingestion  of  milk  once  in  measured  quantity  could  not  have 
led  to  it,  as  the  amount  of  sugar  passed  was  greatly  in  excess 
of  the  lactose  in  the  milk. 

In  my  own  opinion,  the  effect  of  mental  excitement  and 
psychical  influences  in  general  on  diseases  of  the  urinary  or- 
gans has  not  received  the  attention  it  merits.  In  my  work  on 
Bright's  disease  I  have  advised  the  strictest  attention  to  psy- 
chical influences  throughout  the  entire  treatment.  This  is  espe- 
cially needful  in  the  case  of  children  who  have  mental  terrors  and 
annoyances  from  which  adults  are  free.  Few  writers  on  diseases 
of  children  pay  attention  to  the  difficulties  which  lie  in  the  way 
of  successful  treatment  of  many  disorders  in  nervous,  sensitive 
children,  the  real  root  of  whose  diseases  is  often  found  in  men- 
tal suffering  consequent  upon  depressing  psychical  conditions. 

The  Urine  in  Diabetes  Mellitus. — Complete  analyses  of  the 
urine  of  children  are  seldom  reported.  Tyson  records  a  case 
in  a  girl  four  and  a-half  years  of  age  who  passed  sixty-five  to 
two  hundred  fluidounces  of  urine  per  diem,  specific  gravity 
ranging  from  1027  to  1040,  sugar  fifteen  to  thirty-four  grains 
per  ounce.     This  child  died  at  five  years  of  age. 

Purdy  gives  figures  of  an  analysis  made  in  one  case,  which 
will  be  found  under  the  caption  "  Reports  of  Cases." 


DIABETES  MELLITUS. 


475 


I  have  been  sufficiently  fortunate  to  have  the  twenty-four 
hours'  urine  collected  several  times  in  one  case  of  a  boy  of  ten. 
The  following  is  a  complete  report  of  analyses  made  by  me : 


First  Analysis. 

Second. 

Third. 

Fourth. 

Fifth. 

Volume  of  urine  in  24  hours  |  ^^cnr^c' 

42  fl.  ozs. 
1250  c.  c. 

650  c.  c. 

600  c.  c. 

I  to  1 

70  fl.  ozs. 
2000  c.  c. 

IIJO  c.  c. 

850  c.  c. 

i^toi 

85  fl.  ozs. 
2550  c.  c. 

1750  c.  c. 

S6OC.  c. 
2  to  I 

33  fl.  ozs. 
1000  c.  c. 

Ratio  of  day  to  night 

27 

I2>^ 

34 
54° 

II 

S 

22 

35° 

5 

2^ 
12% 

'95 

29 
45° 

Urea,  grains  per  fluidounce 

2 
I 

2-5 

40 
13  to  I 

0.9 
0.5 
1.8 

28 

12  to  I 

0.65 
0.30 
1.66 

2S 

8  to  I 

2.12 
I. 

2.13 
32 

14  to  I 

Phosphoric  acid,  grains  per  ounce 

Phosphoric  acid,  grams  per  24  hours 

Phosphoric  acid,  grains  per  24  hours 

Ratio  of  urea  to  phosphoric  acid 

Sugar,  grams  per  litre 40 

O.I 

36 

17 

72 

1116 

3K 
3^  to  I 

58 

27 

148 

229s 

5 
12  to  I 

6 

3 

6 

92 

0.2  to  I 

Sugar,  grams  per  24  hours 70 

Sugar,  grains  per  24  hours 10S5 

Sugar,  per  cent 4 

Specific  gravity 1030 

Acidity Normal. 

Sediment Uric  acid. 

1028 

Deficient. 

Calcium 
phos.  and 

oxalate. 

1036 
Normal. 

1037 
Normal. 
Urates. 

1029 
Increased. 
Uric  acid. 

The  urine,  then,  fluctuated  between  33  and  85  fluidounces  ; 
the  specific  gravity  between  1028  and  1037  I  the  sugar  between 
one-tenth  and  5  per  cent.;  the  urea  between  195  and  540  grains 
per  twenty-four  hours;  and  the  phosphoric  acid  between  25 
and  40  grains  per  twenty-four  hours.  The  greatest  fluctuation 
was  in  the  ratio  of  sugar  to  urea,  which  ranged  from  0.2  to  i 
to  as  high  as  12  to  i.  The  first  analysis  was  made  three  months 
before  the  fifth. 


476  THE  DISEASES  OF  CHILDREN. 

It  is  now  more  than  a  year  since  I  saw  the  case  in  consulta- 
tion. The  patient  is  still  alive  and  reported  to  be  improving. 
Diabetic  diet  reduced  the  quantity  of  sugar,  but  did  not  im- 
prove general  condition  of  the  patient,  who  is  now  on  mixed 
diet,  avoiding,  however,  sugar. 

In  the  case  of  a  girl  of  twelve  years  of  age  (analysis  made  by 
my  assistant,  Dr.  R.  W.  Lane),  the  figures  were  as  follows : 

Urine  for  24  hours,  1890  c.  c,  93  fluidounces. 

Urea,  23  grams  per  litre. 

Urea,  43  grams  per  24  hours. 

Phosphoric  acid,  i  gram  per  litre. 

Phosphoric  acid,  1.89  grams  per  24  hours. 

Sugar,  3  per  cent. 

Specific  gravity,  1035. 

Analysis  made  August  30,  1893  ;  patient  said  to  be  losing 
flesh  gradually,  and  sugar  still  present.     (February,  1894.) 

Acidity. — According  to  Derignac,  the  total  acidity  in  diabetic 
urine  increases  with  the  proportion  of  sugar,  with  that  of  phos- 
phoric acid,  and  that  of  urea.  It  always  increases  at  the 
moment  of  the  appearance  of  attacks  due  to  the  presence  of 
acetones.  It  constitutes,  then,  an  important  prognostic  sign, 
and  permits  the  physician  to  foresee  these  attacks,  and  enables 
him  to  overcome  them  by  appropriate  therapeusis. 

Phosphaturia. — In  two  cases  in  diabetic  children,  Cerne 
noticed  excessive  phosphaturia,  each  case  presenting  foci  of 
gangrene.  Purdy  mentions  "excess  of  phosphates  "  in  his 
case.* 

Acetone. — This  substance,  and  also  diacetic  acid,  oxybutyria 
acid,  etc.,  have  already  been  mentioned. 

Prognosis. — The  prognosis  in  children's  cases  is  bad.  Seven- 
ty-five per  cent,  of  the  cases  observed  by  Stern  died.  Of 
seventy-seven  cases  traced  by  him  to  a  termination,  fourteen 
recovered,  seven  improved,  four  remained  unimproved,  and 
fifty-two  died.  It  is  worth  while,  however,  to  note  that  the 
prognosis  is  not  so  hopeless  as  older  authorities  would  have  us 
believe. 

Course. — The  disease  runs  a  more  rapidly  fatal  course  in 
children  than  in  adults,  but  the  duration  of  the  disease  varies 
greatly.  In  thirty-four  cases  reported  by  Stern,  the  shortest 
died  in  two  days,  the  longest  was  still  alive  at  the  end  of  five 
years;  in  seven  cases  death  took  place  in  one  month,  in  all  but 
one,  which  recovered.  Seventeen  lasted  less  than  a  year,  and 
of  these,  seven  were  cured.     Ten  lasted  over  a  year,  and  not 


*  It  would  be  clearer  if  writers  would  specify  wfietlier  they  mean  excess  of  PjOj,  or 
simply  an  abundant  sediment  of  earthy  phospha'tes.  Sn  the  case  which  I  saw  there  was- 
neither  condition. — C.  M. 


DIABETES  MELLITUS.  477 

one  recovered.  As  a  rule,  the  smaller  the  child,  the  quicker 
the  course  of  the  disease ;  exceptions  have  been  noted ;  thus, 
a  child  of  four  died  after  two  days  of  diabe*^  .  and  a  child  born 
with  diabetes,  recovered  in  eighteen  months. 

Cases  are  reported  by  Prevost,  Tyson,  Deane,  Henricius, 
Roberts,  Kelly,  Becquerel,  Drummond,  Anderson,  Frew,  D.  P. 
Allen,  Rachford,  De  Bary,  and  McCrea,  which  were  fatal  in  the 
following  time  :* 

Six  days,  Seven  days.  Nine  days,  Eleven  days. 

Three  weeks.  Six  weeks,  Six  weeks, 

Three  months,  Four  months,  Five  months,  Six  months, 

Nine  months.  Twelve  months. 

Eighteen  months,  Eighteen  months  after  observation. 

Kelly's  case  was  a  boy  of  ten,  previously  healthy,  who  died 
in  eleven  days  from  diabetes  following  over-exertion,  profuse 
perspiration  and  cold.  Drummond's  case  was  a  boy  of  seven, 
who  died  of  diabetic  coma  five  months  after  receiving  a  blow 
on  the  head, 

Seegen  classes  children  as  examples  of  cases  in  which  glyco- 
suria continues  regardless  of  food.  In  the  case  which  I  saw, 
however,  rigorous  diet  diminished  the  sugar  to  a  trace,  for  a 
time,  at  least. 

Kiihl  finds  two  forms  of  the  disease,  one  mild  or  slow,  and 
the  other  severe,  both  terminating  fatally.  The  latter  is  found 
among  the  poorer  classes,  which  receive  less  and  later  medical 
attention. 

Treatment. — Inasmuch  as  the  chances  for  recovery  are  but 
slight,  one  in  four  at  best,  probably,  the  patient  should  have 
everything  in  his  favor,  and  be  very  carefully  handled,  the 
urine  examined  frequently,  and  closest  attention  paid  to  every 
little  detail.  Children  with  diabetes  are  notoriously  fond  of 
sweets,  and  often  very  sly  in  obtaining  them.  If  diabetic  diet 
at  once  diminishes  the  quantity  of  sugar  to  a  marked  degree, 
great  fluctuations  in  the  quantity  of  sugar  during  supposed 
adherence  to  diet  should  suggest  that  the  child  cannot  be 
trusted. 

Dr.  Purdyt  has  called  attention  to  the  fact  that  not  infre- 
quently the  diabetic  patient  becomes  cunning  and  deceitful  in 
minor  matters,  especially  those  relating  to  his  food,  and  quotes 
Dickinson,  who  says,  "The  mind  deteriorates  morally  and  intel- 
lectually." I  think  it  good  policy  not  to  assume,  then,  that  a 
diabetic  child  will  refrain  from  eating  forbidden  sweets  merely 
because  he  says  he  will. 


*  Arranged  according  to  time, 
■i""  Diabetes,''  Chicago,  1890. 


478  THE  DISEASES  OF  CHILDREN. 

The  first  thing  in  the  treatment  should  be  gradual  adoption 
of  strict  diabetic  diet,  watching  its  effect  closely,  and  relaxing 
it  if  sudden  onset  of  nervous  symptoms  occur.  If  not,  the 
diet  should  be  continued  for  several  months,  to  be  gradually 
relaxed  when  the  maximum  good  effect  has  been  reached,  and 
to  be  begun  at  once  again  when  the  improvement,  if  any,  fol- 
lowing relaxation,  ceases,  other  things  being  equal. 

Dietetics,  even  in  diabetes,  is  not  an  exact  science,  and  must 
be  used  with  observation  both  of  the  urine  and  of  subjective 
symptoms.  In  general,  however,  reckless  disregard  of  diet 
leads  to  rapid  and  unfavorable  termination. 

Diet  in  Diabetes. — The  patient  should  begin  the  diet  by 
cutting  off  saccharine  foods,  candy  and  the  like  ;  then  in  a 
week,  say,  potatoes  ;  next,  desserts  made  of  flour,  together 
with  sweet  fruits;  finally,  all  cake,  cakes,  and  bread  made  of 
ordinary  flour.  It  is  well,  I  think,  to  cut  off  bread  last  of  all ; 
moreover,  if  it  can  be  proved  that  cutting  off  bread  and  purely 
animal  diet  do  not  reduce  the  quantity  of  sugar  perceptibly 
after  a  week's  trial,  if  necessary',  then  I  allow  a  little  bread,  in 
quantity  not  to  exceed  two  ounces  daily.  Finally,  animal  diet, 
meats,  eggs,  fish  and  gelatin,  if  more  liberal  diet  fail  to  cause 
sugar  to  disappear. 

Articles  Allowed. — Clam-water. 

Fish,  without  flour  sauce.  (No  oysters,  and  no  shell-fish 
generally.) 

Meat  soups,  without  flour  or  milk. 

Meats. 

Poultry,  without  dressing  of  bread  or  flour. 

The  following  vegetables  only  :  Lettuce,  spinach,  cauliflower, 
cabbage,  olives,  water-cresses,  mushrooms,  asparagus  tops,  cu- 
cumbers. 

Eggs,  poached,  scrambled,  soft-boiled ;  carefully-made  omelet. 

Cheese. 

Bread  and  butter,  if  allowed  (see  above),  two  ounces  of  bread 
daily,  that  is,  one  small  slice  morning  and  evening. 

Desserts:  Blanc-mange,  made  of  white  of  ^^^,  beaten  up  and 
flavored  with  vanilla,  sweetened  with  a  little  saccharin.  Gelatin 
jellies  sweetened  with  a  little  saccharin. 

Nuts :  Almonds,  hazelnuts,  walnuts,  cocoanuts.  Brazil-nuts. 

Apples,  which  so  many  children  eat  so  freely,  are  not  allowed. 

The  question  of  milk-diet  is  still  a  mooted  one.  Jacobi  says 
that  milk,  skimmed  or  not  skimmed,  forms  a  "  principal  and 
beneficial  part  of  the  diet  "  in  diabetes  in  children. 

Inasmuch  as  cases  of  diabetes  in  young  children  subsisting 
entirely  or  chiefly  on  milk  are,  as  a  rule,  more  fatal  than  those 
in   older  ones,  it  is  difficult  to  draw  deductions  as  to  benefit 


IN  Die  A  TIONS  FOR  REMEDIES.  479 

from  the  use  of  milk.  I  should  not  advise  it  unless  careful 
analyses  of  the  urine  are  to  be  made  to  see  whether  it  does  not 
increase  the  output  of  sugar.  In  a  case  like  that  mentioned  by 
Haig,  where  urea  was  deficient  and  uremic  symptoms  coming 
on,  under  rigid  diet,  I  should  see  no  objection  to  its  use,  coupled 
with  relaxation  of  the  diet. 

Waters  and  Beverages. — Waukesha  or  Bethesda  ;  Saratoga 
Vichy.  If  stimulants  are  necessary,  whisky,  gin,  Budai  imperial 
wine. 

Massage  of  the  whole  body  is  sometimes  useful.  It  should 
not  be  too  vigorous,  and  may  be  employed  daily  between 
breakfast  and  dinner.  Schnee  advises  a  weak  solution  of  mer- 
curic chloride  in  alcohol,  with  a  little  vaseline  to  be  used  in 
rubbing. 

Electricity. — Electricity  may  be  used  in  cases  where  there  is 
great  muscular  weakness. 

A  diet  which  is  intermediate  between  the  rigorous  one  al- 
ready advised  and  the  ordinary  mixed  diet  of  every-day  life,  is 
recommended  by  McNutt  as  being,  in  his  experience,  better 
than  the  exclusive  diet.  McNutt's  diet  is  as  follows  :  The 
diabetic  patient  may  eat — almond  rusks,  almond  biscuits,  gluten 
bread,  gluten  biscuit ;  stale  bread  (toasted)  sparingly ;  bacon, 
butter,  cheese,  eggs,  beef-tea,  and  thin  soups;  beef,  mutton, 
game,  and  poultry ;  fish,  oysters  ;  cabbage,  lettuce,  string-beans, 
green  peas,  tomatoes,  spinach,  greens,  olives,  artichokes,  as- 
paragus ;  custards  without  sugar,  jellies  unsweetened ;  tea, 
coffee,  cocoa  without  sugar ;  water,  mineral  waters,  claret, 
milk,  buttermilk,  acid  fruits,  lemons,  cherries,  currants,  straw- 
berries, nuts. 

I  have,  myself,  tried  such  a  diet  in  several  adult  cases*  with 
apparent  benefit. 

INDICATIONS  FOR  REMEDIES. 

Arsenicum  takes  first  rank  in  the  treatment  of  diabetes  in 
children.  Indications  are  as  follows:  loss  of  flesh,  great 
hunger  and  thirst,  pallor,  loss  of  strength,  tendency  to  gan- 
grene, dryness  of  the  throat  and  mouth,  watery  diarrhea, 
dyspnea  on  slight  exertion.  Treatment  should  begin  with  the 
third  decimal  trituration,  three  grains,  four  times  daily,  con- 
tinued over  a  long  period  of  time,  the  dose  being  gradually 
increased  until  one  grain  of  the  second  decimal  or  its  equiva- 
lent is  given.  Arsenicum  should  be  given  in  the  sixth  deci- 
mal trituration  in    case   aggravation   occurs  from   the    lower 


*  See  "  Disease  of  the  Kidneys,"  page  383. 


480  THE  DISEASES  OF  CHILDREN. 

potencies,  preferably  also  in  the  case  of  very  young  children 
and  infants. 

Lithium  is  undoubtedly  of  benefit  in  some  cases.  I  have 
found  it  beneficial  in  adults  and  suggest  a  trial  of  it  in  the  case 
of  children.  I  have  found  nothing  superior  to  it  for  relieving 
the  rheumatoid  pains  which  are  sometimes  very  severe  in  con- 
nection with  hyper-acid  urine  and  uric-acid  sediments.  I  have 
used  it  in  adults  in  the  form  of  benzoate,  in  doses  of  from  ^  to 
2  grains  of  the  chemically  pure  crude  drug,  four  times  daily. 
For  children,  the  first  decimal  trituration  might  be  used.  Fif- 
teen- to  30-drop  doses  of  lithiated  hydrangea,  so  useful  in 
larger  doses  for  adults,  should  be  thought  of  also. 

Salicylate  of  Sodium  has  been  advocated  in  the  treatment  of 
diabetes  by  Jacobi,  Haig,  and  others,  given  with  an  alkaline 
water,  like  vichy  or  seltzer.  Jacobi  says  that  a  child  of  five  can 
take  5  to  8  grains  (0.32  to  0.52  grams)  three  times  daily  and 
continue  its  use  many  weeks.  Haig  claims  that  it  sometimes 
increases  the  urea  sugar  ratio  ;  in  the  case  of  a  girl  of  eight,  dia- 
betic diet  caused  great  fall  in  urea  and  brought  on  a  lethargic 
condition  ;  she  was  put  by  Haig  on  mixed  diet  and  milk,  to- 
gether with  10  grains  of  salicylate,  four  times  daily,  and  the 
ratio  of  urea  to  sugar  rose.  I  am  inclined  to  think,  however, 
that  the  relaxation  of  the  diet  had  much,  if  not  all,  to  do  with 
this  matter. 

Kreasote. — Heaviness,  drowsiness,  depression  of  spirits,  head 
confused  and  dull ;  very  severe  chronic  neuralgic  troubles.  To 
be  given  in  the  third  decimal  trituration. 

Phosphoric  Acid. —  Of  value  when  the  case  is  evidently  of 
nervous  origin  ;  when  there  is  loss  of  fluids ;  patient  is  indif- 
ferent to  all  things  ;  long-lasting  diarrhea.  For  thirst,  potas- 
sium phosphate,  two  parts,  in  water  75  parts  ;  teaspoonful  three 
times  daily  in  a  little  hot  tea. 

Uranium  Nitrate. — Languor  marked  and  general ;  excessive 
thirst.  Useful  in  cases  originating  in  gastro-intestinal  derange- 
ment.    To  be  given  in  the  third  decimal. 

Jumbul. — This  drug  is  still  used  extensively  in  adult  cases.  It 
is  said  not  to  be  beneficial  in  cases  where  the  patient  is  on  mixed 
diet.  I  have  no  record  of  its  value  in  the  diabetes  of  children, 
but  should  be  inclined  to  try  it  where  polyuria  resisting  diet 
was  a  feature.  It  might  be  given  in  grain  doses  of  the  seeds 
four  times  daily. 

Other  remedies  often  indicated  from  time  to  time  in  adult 
cases,  and  hence  not  to  be  forgotten  in  children,  are  bryonia, 
lactic  acid,  leptandra,  podophyllum,  aurum  muriaticum,  nitric 
acid,  mercurius  solubilis,  graphites.* 

*See  Mitchell's  "  Diseases  of  the  Kidneys,"  2d  edition. 


NOTES   ON  TREATMENT.  481 

MISCELLANEOUS   NOTES   ON   TREATMENT. 

Stern,  who  has  seen  a  large  number  of  cases  in  children,  relies 
chiefly  on  dietetic  treatment.  Next  to  this  he  advocates  the 
diet  and  bath  at  such  places  as  Neuenahr,  Carlsbad,  and  Vichy. 
Alkaline  bicarbonates  are  the  best  drugs,  though  none  are  spe- 
cially curative. 

Schnee  claims  to  have  cured  four  children,  ages  nine  to  thir- 
teen years,  one  of  his  cases  still  showing  no  sugar  five  years 
after  cure.  His  treatment  was  Carlsbad  water,  Turkish  baths, 
internal  remedies,  and  massage  of  the  whole  body.  In  the  case 
of  a  girl  of  nine,  cure  was  brought  about  by  the  use  of  Carlsbad 
water  for  two  months  in  conjunction  with  Russian  baths  and 
wet-sheet  packings,  massage  of  the  whole  body  and  internal 
medicines.  He  does  not  name  the  latter,  but  in  another  part 
of  his  work  praises  Bamberger's  formula  for  corrosive  sublimate- 
albuminate  and  potassium  bichromate,  using  these  remedies 
both  internally  and  externally  by  massage. 

Treatment  of  Diabetic  Coma. — Preventive  treatment,  if  pos- 
sible, is  the  only  one.  Fatigue,  especially  that  from  travel,  is 
to  be  guarded  against ;  diet  relaxed,  and  the  bowels  opened 
with  castor  oil.  When  patient  begins  to  be  drowsy  and  to  have 
pains  in  the  stomach,  give  hot  bath  and  make  hot  applications 
to  extremities.  Try  also  sodium  bicarbonate  in  lo-grain  doses 
hourly. 

Reports  of  Cases. — Inasmuch  as  diabetes  in  children  has 
hardly  received  merited  attention,  it  will  not,  I  hope,  be  out 
of  order  to  quote  reports  of  the  following  cases  found  in  the 
journals: 

Dr.  J.  S.  Thatcher  exhibited  a  specimen  of  blood  removed 
from  a  girl  fifteen  years  of  age,  in  the  service  of  Dr.  Beverly 
Robinson  at  St.  Luke's  Hospital.  "About  four  or  five  months 
before  her  death  she  began  to  lose  flesh  and  strength,  and  to 
suffer  from  great  thirst.  During  the  three  months  she  was  in 
the  hospital  the  urine  contained  no  albumin,  and  the  daily 
average  of  sugar  was  from  four  to  six  per  cent.  She  gained  in 
weight  slightly  immediately  after  admission,  but  afterwards 
lost  flesh  steadily.  The  day  before  her  death  she  was  up  and 
around  the  ward  ;  about  ten  hours  before  death  she  was  found 
to  be  cold,  and  suffering  from  labored  breathing,  and  three  hours 
later,  after  a  dose  of  morphin,  she  was  found  asleep,  with  a 
pulse  of  130,  and  respirations  16  and  very  deep.  About  six 
hours  before  death  she  was  seized  with  a  tonic  spasm,  which 
lasted  for  about  ten  minutes,  and  was  succeeded  by  coma  which 
continued  until  her  death.  All  the  vessels  in  which  any  blood 
was  found  contained  blood  of  white  color,  or  of  the  pinkish 
D.  C— 31 


482  THE  DISEASES  OF  CHILDREN. 

hue  shown  in  the  specimen.  In  the  heart  there  were  some 
reddish  coagula  and  a  quantity  of  blood  looking  like  coagulated 
milk.  The  occurrence  of  dyspnea  is  interesting  in  connection 
with  this  fatty  condition  of  the  blood."* 

In  a  clipping  which  I  have  found  from  the  Therapeutic 
Gazette,  in  which  the  name  of  the  writer  has  been  unfortu- 
nately torn  off,  occurs  an  account  of  the  following  case : 

"  This  case  at  the  Chelsea  Infirmary  was  kindly  placed  un- 
der the  treatment  by  Mr.  Moore.  It  was  of  the  so-called  pan- 
creatic type.  A  boy,  aged  thirteen,  whose  father  had  recently 
died  of  diabetes,  had  suffered  from  symptoms  of  diabetes,  be- 
fore beginning  this  treatment,  for  six  months.  From  January 
I,  1892,  he  was  placed  on  diabetic  diet,  and  was  given  first 
codein,  from  which  he  received  no  benefit,  and  then  morphin, 
under  which  he  improved.  The  zymin  treatment,  with  diet  as 
before,  was  begun  May  18.  His  general  condition  was  bad; 
appetite  not  ravenous ;  thirst  great ;  weight,  five  stone,  ten  and 
three-quarter  pounds ;  quantity  of  urine  in  twenty-four  hours 
about  99  ounces;  specific  gravity,  1036  ;  sugar  estimated  at  6.5 
grains  per  ounce.  Zymin  was  given  in  increasing  doses,  with 
the  subsequent  addition  of  sodium  bicarbonate,  and  finally 
pancreatin  pills,  coated  with  keratin,  were  substituted.  A 
daily  record  of  the  amount  and  specific  gravity  of  the  urine 
was  kept,  and  quantitative  estimates  of  sugar  were  made  with 
Fehling's  solution.  The  treatment  was  continued  till  August 
21,  when  he  left  the  infirmary.  Unfortunately,  owing  to  decep- 
tion on  the  part  of  the  patient,  and  dietetic  indiscretions,  which 
caused  diarrhea  on  more  than  one  occasion,  many  of  the  obser- 
vations are  valueless,  and  with  the  amount  of  comment  neces- 
sary would  be  out  of  place  in  this  summary.  What  is  certain 
is,  that  his  general  condition  vastly  improved,  his  weight  in- 
creased 7^  ounces  and  thirst  diminished.  During  the  first 
ten  days  of  treatment  the  amount  of  urine  in  twenty-four  hours 
averaged  78  ounces,  and  for  the  last  ten  days  before  leaving  it 
averaged  35  ounces,  while  the  specific  gravity  for  the  same 
periods  averaged  1036  and  1027  respectively.  The  first  reliable 
quantitative  estimation  of  sugar,  made  May  20,  gave  6.5  grains 
to  the  ounce;  the  last,  made  at  the  end  of  June,  4.5  grains. 
The  boy  was  re-admitted  November  5,  and  is  still  in  the  in- 
firmary. He  is  improving  under  opium,  but  has  not  reached 
the  standard  of  last  summer  under  the  pancreatic  treatment. 

"  No  definite  deduction  can  be  made  from  this  case,  owing  to 
the  facts,  already  mentioned,  that  he  was  improving  at  the 
time   zymin   was   commenced,    and   the   intractability  of  the 


*  Medical  Record. 


NOTES  ON  TREATMENT.  483 

patient,  while  the  summer  weather  and  the  continuance  of 
restricted  diet  were  in  his  favor." 

Dr.  W.  D.  Hamaker*  reports  the  following  case : 

E.  H.,  female,  white,  aged  fifteen  years;  consulted  me  No- 
vember 7,  1887,  with  the  following  history:  She  had  the  ordi- 
nary diseases  of  childhood ;  had  had  scarlet  fever  when  two 
years  old.  No  history  of  rheumatism  nor  of  any  fright  or 
shock.  She  began  to  menstruate  in  June  last;  menses  scanty 
and  pale.  No  disease  could  be  discovered  on  the  father's  or 
mother's  side,  except  that  one  aunt  had  chorea. 

In  July  she  failed  in  health,  and  about  two  months  before 
coming  to  me,  she  began  to  have  a  ravenous  appetite,  with  loss 
of  flesh,  great  thirst  and  increased  amount  of  urine.  These 
increased  rapidly,  and  on  November  7  she  presented  great 
emaciation,  pale  skin,  dry,  fissured  tongue  and  hay-like  odor  of 
breath. 

November  8. — She  weighed  87  pounds,  and  the  amount  of 
urine  in  twenty-four  hours  was  36  pints,  with  a  specific  gravity 
of  1028,  and  giving  a  strong  reaction  with  Fehling's  solution. 
She  was  also  troubled  with  pruritus  vulvae.  I  put  her  on  1-24 
grain  of  strychnin  and  3  grains  of  ergotin  t.  d.,  and  a  strict 
diabetic  diet. 

November  14. — Urine  diminished  to  12  pints,  with  specific 
gravity  of  1026.  Was  able  to  keep  her  on  the  diet  very  easily. 
Thirst  was  much  diminished. 

November  21. — Put  her  on  three  grains  of  carbonate  of  lith- 
ium and  i-io  grain  of  arseniate  of  sodium  per  diem,  dissolved 
in  a  quart  of  water.  This  is  to  be  drunk  at  meal  time.  No 
other  medicine  was  given,  and  the  diet  was  continued  as  before. 
Not  much  liquid  allowed,  except  a  couple  of  glasses  of  milk 
and  the  water  taken  with  the  medicine. 

November  28. — Amount  of  urine  per  diem  11  to  12  pints  in 
the  last  week ;  weight  86  pounds ;  feels  much  better ;  thirst 
not  marked  ;  no  pruritus.  A  large  alveolar  abscess  opened  to- 
day.    General  appearance  of  patient  much  improved. 

November  29. — Last  night  was  the  first  night  in  which  she 
was  not  compelled  to  rise  to  urinate. 

December  i. — Weight  87  pounds. 

December  3. — Arseniate  of  soda  continued  at  i-io  grain 
per  diem,  but  the  lithium  carbonate  increased  to  12  grains  per 
diem. 

December  8. —  Medicine  and  diet  continued  as  before.  Patient 
feels  better  and  looks  better;  drinks  very  little. 

December  13. — Reduced  liquids  to  one  pint  of  water  with  the 


*  Therapeutic  Gazette. 


484  THE  DISEASES  OF  CHILDREN. 

medicine.  Allow  no  tea,  coffee,  apples  or  oranges,  and  as  little 
water  or  milk  as  possible  ;  weight  87  pounds. 

December  20. — Strong  and  bright ;  specific  gravity  of  urine, 
1028.  From  November  28  to  present  date  the  amount  daily- 
has  been  from  9  to  12  pints. 

December  24. — Quantitative  analysis  showed  22  grains  of 
sugar  to  the  ounce.  This  was  the  only  quantitative  analysis 
made. 

January  2. — Weight  87  pounds;  specific  gravity  1022;  gen- 
eral health  improving.  Patient  has  adhered  strictly  to  diet 
and  the  treatment  continued  as  before.  A  small  piece  of  well- 
done  toast  was  allowed  twice  a  day,  but  immediately  the  urine 
increased  in  amount.     The  toast  was  stopped  at  once. 

January  8. — The  daily  amount  of  urine  continues  at  10  to  12 
pints ;  specific  gravity,  1022.  Apparently  she  was  doing  as 
well  as  before. 

I  did  not  see  the  patient  again  till  January  16,  when  I  found 
her  almost  comatose,  with  labored  breathing ;  tongue  and  lips 
dry  and  parched  ;  some  pain  in  the  chest  and  great  deafness ; 
specific  gravity  of  urine,  1015;  and  strong  reaction  was  shown 
on  testing  for  acetone.     Death  ensued  the  following  day. 

In  this  case  the  new  treatment  was  faithfully  carried  out  in 
every  detail  for  eight  weeks,  and  until  one  week  before  her 
death  there  was  apparent  improvement ;  but  the  sudden  change, 
the  onset  of  coma,  the  presence  of  acetone  and  the  other  symp- 
toms showed  no  difference  from  the  termination  of  cases  treated 
by  the  old  methods. 

My  next  case  I  shall  treat  in  the  same  way ;  for  we  should 
give  a  fair  trial,  in  so  intractable  a  disease,  to  any  method 
which  promises  to  be  successful  in  even  a  few  cases. 

Dr.  F.  C.  Simpson  reports  the  following  :* 

"  John  S.  ;  boy  three  and  a-half  years  old  ;  parents  living  and 
healthy ;  neither  parent  showing  any  hereditary  taint  as  to 
diabetes.  I  saw  him  on  October  23,  1891 ;  he  seemed  to  be 
well-nourished  and  what  I  would  call  a  fairly  healthy  boy.  I 
gleaned  from  the  parents  the  following  history : 

"The  boy  had  for  the  past  three  weeks  showed  decided 
muscular  weakness,  increased  urination  and  quite  a  thirst, 
drinking  quite  a  quantity  of  water  during  the  twenty-four 
hours.  He  also  had  a  partial  loss  of  appetite,  which  is  contrary 
to  the  habit  in  the  majority  of  these  attacks.  He  was  very 
fond  of  sweet  things,  and  was  allowed  to  eat  freely  of  these, 
such  as  preserves,  candy,  etc.  Upon  inquiry,  his  mother 
thought  that  he  must  have  passed  about  three  and  one-half 


*  American  Practitioner  and  News. 


NOTES  ON  TREATMENT.  485 

pints  to  four  pints  of  urine  in  twenty-four  hours.  He  asked 
for  water  while  I  was  examining  him,  and  drank  off  a  glass 
without  stopping.  I  asked  for  a  sample  of  his  urine,  which 
was  sent  me  the  next  morning,  the  first  he  had  passed  after 
getting  out  of  bed.  Test  of  urine :  Color,  straw ;  reaction, 
alkaline;  specific  gravity,  1040.  Upon  adding  the  urine  to 
Fehling's  solution  under  heat,  it  turned  a  yellow  color,  which 
was  at  once  precipitated  to  a  copper-red,  showing  conclusively 
that  sugar  was  present.  I  afterwards  had  a  quantitative  test 
made,  and  the  report  was  about  three  grains  of  sugar  to  the 
ounce.  At  this  time  the  boy's  parents  gave  another  chapter  in 
the  history,  in  which  it  was  brought  out  that  the  little  fellow 
had  fallen  down  stairs  (about  fifteen  or  twenty  steps)  just  be- 
fore the  time  that  they  had  noticed  the  symptoms  detailed 
above.  In  the  fall  the  boy  did  not  become  unconscious,  and 
there  was  nothing  more  than  a  scare.  He  did  not  complain 
of  any  pain  about  the  head ;  in  fact,  he  seemed  to  be  all  right 
in  a  few  minutes,  and  never  showed  any  signs  of  after-effect. 

"  I  made  another  examination  of  his  urine  at  the  end  of  a 
week,  and  found  there  was  a  slight  decrease  in  all  his  symptoms 
and  not  as  much  sugar;  specific  gravity,  1030.  His  mother 
said  he  did  not  show  as  much  thirst,  and  the  quantity  passed 
was  only  three  pints  during  the  twenty-four  hours.  I  had  in- 
structed her  carefully  to  measure  each  quantity  passed.  I  saw 
the  child  at  the  end  of  two  weeks,  and  a  sample  of  his  urine 
showed  a  specific  gravity  of  1024.  Fehling's  test  showed  sugar 
in  very  small  quantity.  I  had  a  quantity  test  made,  and  it 
showed  only  one  grain  to  the  ounce.  His  general  health  was 
greatly  improved  ;  thirst  was  not  as  great,  and  the  quantity  of 
urine  was  only  two  pints  in  the  twenty-four  hours. 

"  The  treatment  was  ergot  and  bicarbonates,  and  this  was 
the  only  treatment  he  received  during  the  three  weeks.  He 
has  continued  to  improve  from  the  beginning  of  treatment,  and 
at  the  end  of  four  weeks  the  urine  is  normal.  His  general 
health  is  greatly  improved,  and  I  have  made  examinations  of 
his  urine  every  week,  and  found  nothing  abnormal.  I  consider 
the  boy  cured  of  his  diabetes." 

The  following  questions  may  be  pertinently  asked  :  What 
was  the  cause  of  this  glycosuria?  Was  it  due  to  injury  of  the 
brain  induced  by  the  fall,  or  was  it  due  to  the  causes  that  pro- 
duce diabetes  we  so  frequently  see  in  the  adult  ?  The  nervous 
element  was  the  predisposing  cause,  and  the  shock  had  some- 
thing to  do  with  producing  the  saccharine  urine. 

Leva  saw  a  case  in  a  girl  of  twelve,  of  healthy  parents,  nine 
months  ill.  It  began  without  known  cause,  with  intense  thirst, 
rapid    emaciation,    cramps   in    the   calves,   and   soon    intefise 


486  THE  DISEASES  OF  CHILDREN. 

glycosuria,  polyphagia,  polydipsia,  polyuria,  and  malaise.  On 
the  fifth  day  after  treatment  was  begun  coma  set  in,  and  death 
followed  in  two  days.  Autopsy  showed  atrophied  heart,  ate- 
lectasis of  deep  portions  of  the  lungs,  slight  enlargement  of  the 
spleen,  enlarged  kidneys,  and  milky  condition  of  the  blood. 

Shaffer  reports  a  case  of  a  boy  of  fourteen  years,  who  had  never 
been  ill  until  on  a  certain  date  (December  27)  he  was  thirsty 
and  passed  much  water  at  night.  On  January  4  he  went  skat- 
ing. On  January  5  he  had  dyspepsia,  constipation,  excessive 
micturition,  and  thirst.  On  the  8th  there  was  labored  respira- 
tion, mostly  thoracic,  with  decided  hebetude.  On  the  9th,  at 
midnight,  he  was  moribund,  but  rallied  under  stimulants  and 
external  applications.  Temperature,  96°  to  98°.  He  became 
comatose  at  10:30  A.  M.,  and  died. 

Watkins-Pitchford  reports  a  case  in  a  boy  eight  years  and 
nine  months  old,  who,  for  a  fortnight,  had  had  dry  mouth  and 
throat  ;  polyuria  ;  urine,  1035  in  specific  gravity  ;  no  albumin, 
but  sugar  present.  The  pulse  was  80  and  strong.  A  few  days 
after,  being  placed  on  diabetic  diet,  respirations  doubled  in  fre- 
quency, but  there  were  no  physical  signs.  He  vomited  once  or 
twice  at  intervals  of  a  few  hours,  and  the  temperature  was  sub- 
normal. He  died  on  the  following  day.  During  the  twenty- 
four  hours  prior  to  death  he  passed  16  ounces  of  urine,  of  a 
specific  gravity  of  1040,  strongly  acid,  plenty  of  sugar  and  yi 
albumin.  His  mother  had  died,  eighteen  days  previous  to  the 
beginning  of  the  boy's  illness,  of  phthisis  pulmonalis. 

Dr.  C.  W.  Purdy  reports  the  following  case  : 

Case  223. — B.  G.,  December  31,  1888.  Patient's  age  four 
years  and  three  months.  His  mother  first  noticed,  in  August 
last,  that  he  was  urinating  very  frequently,  "  wetting  the  bed  " 
at  night.  About  the  same  time  he  became  very  thirsty.  He 
has  recently  lost  considerably  in  weight.  He  complains  of  be- 
ing weak  and  tired  much  of  the  time.  His  mother  states  that 
he  urinates  about  every  half-hour.  Careful  inquiry  fails  to  re- 
veal any  history  of  diabetes  in  the  family,  but  tuberculosis  is 
prominent.  The  patient  has  had  no  serious  illness  before,  but 
he  fell  upon  the  floor  of  a  car  a  short  time  before  his  present 
illness  began,  and  sustained  a  severe  blow  upon  his  head.  His 
urine  to-day  is  clear  ;  color,  light  greenish-yellow  ;  acid  reaction  ; 
specific  gravity,  1033  ;  and  contains  20  grains  of  sugar  to  the 
ounce.  The  urine  is  free  from  albumin.  The  patient  was 
ordered  a  diet  of  milk,  meats,  a  little  cracker,  and  some  green 
vegetables.     No  medicines  were  prescribed. 

January^,  1889. —  Urine  to-day :  specific  gravity,  1025  ;  sugar, 
12  grains  to  the  ounce. 


NOTES  ON  TREATMENT.  487 

February  4. — Urine :  specific  gravity,  1030 ;  sugar,  10  grains 
to  the  ounce,  no  albumin  ;  diuresis  and  thirst  greatly  dimin- 
ished ;  he  gives  his  nurse  no  more  trouble  at  night  from  calls 
to  urinate.  The  family  physician  now  volunteered  to  cure  the 
patient,  and,  as  my  prognosis  was  such  as  to  afford  the  parents 
no  hopes  of  recovery,  the  patient  passed  into  the  hands  of  the 
more  sanguine  physician. 

October  14,  1889. — The  parents  of  the  child  returned  and  re- 
quested me  to  resume  treatment  of  the  case.  Examination  of 
the  patient  showed  extreme  emaciation,  great  thirst,  and  diu- 
resis. The  patient  had  been  permitted  a  mixed  diet,  including 
all  fruits  and  farinaceae,  and,  as  a  consequence,  the  disease  had 
progressed  at  a  rapid  pace.  Examination  of  the  urine  resulted 
as  follows :  color  light ;  reaction  acid  ;  specific  gravity  1038  ; 
sugar  present,  25  grains  to  the  ounce;  urea,  .013  gram  to  the 
cubic  centimetre  of  urine  (13  grams  per  litre,  6  grains  per 
fluidounce) ;  phosphates  greatly  in  excess ;  the  urine  is  free 
from  albumin ;  the  patient  seems  tired,  weak,  restless,  and  has 
little  or  no  appetite.  He  was  put  on  milk  with  a  little  bread, 
and  quinin  was  ordered  in  i-grain  doses  three  times  a  day. 

October  18. — The  appetite  has  somewhat  improved,  and  the 
patient  seems  less  weak.  The  urine  to-day  is  clear  ;  acid  in  re- 
action ;  specific  gravity,  1033,  and  contains  25  grains  of  sugar 
to  the  ounce  ;  phosphates  greatly  in  excess  ;  no  albumin  pres- 
ent ;  diet  to  be  restricted  almost  entirely  to  milk ;  to  continue 
quinin,  3  grains  daily. 

October  21. — Urine,  4  pints;  specific  gravity,  1029;  sugar, 
18  grains  to  the  ounce.     To  continue  treatment  as  before. 

October  28. — The  patient  seems  very  weak ;  has  little  or  no 
appetite.  Urine  to-day:  specific  gravity,  1033;  sugar,  16 
grains  to  the  ounce  ;  phosphates  in  excess ;  no  albumin  present. 

November  4. — Urine  to-day;  specific  gravity,  1029;  clear; 
acid  reaction;  sugar  present,  12  grains  to  the  ounce;  phos- 
phates in  excess.  To  continue  milk  diet,  with  very  little  bread, 
and  some  green  vegetables. 

November  12. — Urine  :  specific  gravity,  1024  ;  acid  reaction; 
sugar,  10  grains  to  the  ounce.  The  patient  is  weak  ;  has  little 
relish  for  food,  and  is  troubled  with  slight  cough. 

November  24. — The  cough  is  better,  and,  on  the  whole,  the 
patient  seems  somewhat  stronger.  Urine,  5  pints ;  specific 
gravity,  1028  ;  sugar,  10  grains  to  the  ounce  ;  no  albumin. 

December  6. — Urine  is  clear ;  color  light  ;  specific  gravity, 
1033  ;  sugar,  10  grains  to  the  ounce. 

December  18.  —  Patient  began  to  complain  of  pains  in  his 
stomach  and  bowels,  and  to  grow  a  little  drowsy  to-day.  His 
respirations  were  somewhat  quickened.     He  was  given  a  hot 


488  THE  DISEASES  OF  CHILDREN. 

bath,  and  hot  bottles  were  applied  to  his  extremities,  and  lo- 
grain  doses  of  sodium  bicarbonate  were  ordered  every  hour. 

December  19. — Patient  is  more  stupid  to-day  ;  sleeps  much  of 
the  time.  The  respirations  have  increased  in  frequency  to  40 
per  minute;  the  temperature  is  101°  Fahr.  The  abdominal 
pains  have  subsided.  Toward  evening  the  patient  became  more 
stupid  and  refused  all  food. 

December  20. — Patient  died  to-day  in  a  comatose  state,  with- 
out convulsions. 


CHAPTER  IX. 

DIABETES  INSIPIDUS. 

Definition. — Diabetes  insipidus  is  a  disease  characterized  by- 
persistent  polyuria,  without  presence  of  sugar  or  albumin  in  the 
urine,  and  usually  accompanied  by  polydipsia. 

Etiology. — The  disease  is  common  in  childhood.  Some  cases 
are  hereditary  in  origin  ;  others  probably  due  to  brain  lesions, 
syphilitic  and  otherwise.  Inveterate  masturbation,  inconti- 
nence of  urine,  or  tapeworm  were  the  only  exciting  causes  as- 
certained in  some  cases.  Cases  are  said  to  originate  from 
trauma,  especially  to  the  head,  or  febrile  attacks.  Violent  mus- 
cular effort  and  violent  mental  emotions  are  said  to  cause  it.  It 
occurs  in  tubercular  meningitis,  epilepsy,  and  hereditary  syph- 
ilis, and  as  sequela  to  acute  infectious  diseases.  It  has  in  some 
instances  been  apparently  traced  to  parents  allowing  young 
children  to  drink  alcoholic  liquors.  Exposure  to  cold,  and 
drinking  cold  fluids  when  heated,  and  exposure  to  hot  sun 
seem  to  have  been  exciting  causes  in  a  few  cases.  Abuse  of 
diuretics  has  been  mentioned  as  an  exciting  cause.  Johanne- 
sen  reports  a  case  in  an  infant  apparently  due  to  the  bite  of  a 
wood-beetle.  In  many  cases  the  etiology  cannot  be  deter- 
mined. In  general  the  disease  is  thought  to  be  a  neurosis 
having  its  origin  in  the  dilatation  of  the  renal  arteries,  from 
paralysis  or  irritation  of  their  vaso-motor  nerves. 

Age.  —  Out  of  70  cases  mentioned  by  Roberts,  7  were  in- 
fants;  15  from  five  to  ten  years  old  ;  13  from  ten  to  twenty, 
and  the  rest  from  twenty  to  seventy,  only  4  being  from  fifty 
to  seventy.  In  other  words,  fifty  per  cent,  of  the  cases  were 
under  twenty  years  of  age,  and  not  quite  fifty  per  cent,  between 
twenty  and  fifty. 

Pathology. — The  disorder  has  no  fixed  pathology.  The  kid- 
neys are  oftener  diseased  than  in  diabetes  mellitus,  but  in  some 
cases  were  apparently  normal.  In  many  instances  lesions  in 
the  flow  of  the  fourth  ventricle,  as  in  diabetes  mellitus,  have 
been  found. 

In  some  of  the  most  acute  cases,  when  emaciation  and  debil- 
ity were  great,  and  polyuria  excessive,  no  pathological  condi- 
tions could  be  found  after  death  sufficient  to  account  for  the 

symptoms. 

(489) 


490  THE  DISEASES  OF  CHILDREN. 

Symptoms. — In  some  cases  polyuria,  which  maybe  excessive, 
is  the  only  symptom. 

Other  symptoms  than  polyuria  most  commonly  seen  are  the 
following  :  Dry,  harsh,  hot  skin  ;  dry  mouth  and  throat ;  emacia- 
tion, thirst,  which  may  be  intense  ;  loss  of  strength  ;  neuralgic 
and  rheumatic  pains.  In  cases  where  the  amount  of  solids  in 
the  urine  is  small  (hydruria),  the  patient  feels  poorly,  is  easily 
chilled,  appetite  is  capricious  and  there  is  a  sinking,  gnawing 
sensation  in  the  pit  of  the  stomach.  In  cases  where  the  total 
quantity  of  normal  solids  voided  in  the  urine  is  large  (polyuria), 
there  are  severer  symptoms,  as  above  noted. 

When  cerebral  lesions  are  present,  disturbances  of  sensibility 
or  of  motion  are  present.  Headache  or  convulsions  may  occur. 
Ptyalism  has  been  noticed  in  several  cases. 

Cases  are  known  in  which  excessive  elimination  of  phosphoric 
acid  occurs.  In  these  cases,  although  sugar  is  absent,  there  is, 
in  addition  to  the  symptoms  mentioned  above,  a  tendency  to 
boils,  ravenous  appetite,  possibly  cataract,  as  in  the  case  of  dia- 
betes mellitus.  This  kind  of  diabetes  insipidus  is  called  phos- 
phatic  diabetes,  and  is  associated  sometimes  with  nervous 
derangements  or  with  phthisis,  sometimes  with  neither.  Again, 
in  some  cases  excessive  elimination  of  the  chlorides  may  be 
noticed  (chlorine  diabetes). 

THE   URINE   IN   DIABETES    INSIPIDUS. 

We  find  two  forms  of  this  disorder,  namely,  hydruria  and 
polyuria.  In  hydruria  the  quantity  of  urine  per  twenty-four 
hours  is  enormous  and  the  specific  gravity  below  1008.  In 
polyuria  the  quantity  of  urine,  though  not  enormous,  is  greatly 
increased,  and  the  specific  gravity  loio  and  upwards. 

The  total  urine  per  twenty-four  hours  is  usually  that  of  fluids 
ingested  ;  but  if  the  fluids  be  cut  off,  the  urine  is  not  diminished 
proportionately.  The  volume  of  urine  per  twenty-four  hours 
is  generally  greater  than  that  of  diabetes  mellitus.  Very  young 
children  have  been  known  to  void  as  much  as  30  pints  in  the 
twenty-four  hours.  Roberts  speaks  of  a  girl  of  ten  who  voided  a 
little  more  than  a  third  of  her  own  weight  of  urine.  Ten  to  15 
pints  daily  (5000  to  7500  c.  c.)  is  not  uncommon  in  the  case  of 
children  afflicted  with  this  disease. 

The  total  solids  are  as  a  rule  above  normal  per  twenty-four 
hours  though  decreased  relatively  (grains  per  ounce,  grams 
per  litre.) 

In  some  cases,  without  great  increase  in  twenty-four  hours' 
urine,  the  total  phosphoric  acid  is  double  or  treble  the  normal 


URINE  IN  DIABETES  INSIPIDUS.  491 

per  twenty-four  hours  (phosphatic  diabetes),  and  the  urea  phos- 
phoric-acid ratio  diminished. 

Peptone  and  hippuric  acid  are  occasionally  found. 

The  urine  is  usually  feebly  acid,  undergoes  alkaline  change 
readily,  and  then  deposits  a  white,  creamy  sediment  of  simple 
phosphates.  The  color  is  from  pale-yellow  to  light-yellow  and 
the  odor  deficient.  When  freshly  voided,  it  is  clear  like  water, 
but  soon  becomes  cloudy  from  presence  of  micro-organisms. 
The  sediment  is  very  scanty  in  the  freshly -voided  urine,  and 
usually  contains  nothing  of  significance. 

I  am  convinced  that  the  ordinary  computation  of  total  solids 
by  Trapp's  co-ef^cient  is  worthless  in  some  of  these  cases, 
especially  in  hydruria. 

Analysis  of  Children  s  Uritie. — Grancher  reports  a  case  in  a 
child  (sex  not  mentioned)  of  eight,  in  which  the  etiology  was  a 
blow  on  the  left  temple.  The  twenty-four  hours'  urine  was  14 
to  16  pints  (7  to  8  litres);  the  specific  gravity,  1003  to  1004; 
urea  1.2  grams  per  litre  (0.5  grains  per  fluidounce)  ;  urea,  total, 
less  than  10  grams  (i  55  grains)  in  twenty-four  hours.  Chloride's 
were  0.7  gram  (i  i  grains),  phosphates  o.io  gram  (i  1-2  grains) 
in  twenty-four  hours. 

This,  then,  is  an  example  of  the  first  class  of  cases  mentioned 
above,  namely,  simple  hydruria.  Now  the  total  solids  in  this 
case  computed  by  Trapp's  co-efficient  would  be  4x2x7,  or  56 
grams,  manifestly  an  absurdity,  as  the  total  urea,  chlorides,  and 
phosphates  all  together,  were  less  than  1 1  grams,  and  it  is  not 
likely  that  the  remaining  constituents,  sulphates,  creatinin,  etc., 
would  amount  to  45  grams. 

Course  and  Prognosis. — The  duration  of  the  malady  is  uncer- 
tain. Congenital  cases  may  last  fifty  to  sixty  years.  Cases 
which  recover  usually  do  so  in  one  or  two  years,  though  recov- 
ery in  a  longer  time  is  not  impossible.  Cases  beginning  sud- 
denly and  those  due  to  blows,  run  a  most  acute  course,  and  may 
die  within  a  few  months,  though  Guinon,  differing  from  other 
authorities,  regards  cases  due  to  trauma,  as  well  as  those  de- 
pendent on  febrile  attacks,  as  especially  curable.  Those  begin- 
ning in  youth  without  known  cause  are  regarded  favorably 
from  the  standpoint  of  prognosis. 

In  some  cases  the  patient  lives  for  years  in  comparatively 
good  health,  succumbing  possibly  to  phthisis,  pleuro-pneu- 
monia,  or  organic  disease  of  the  brain,  since  diabetes  insipidus 
is  seldom  fatal  by  its  own  virulence. 

Owing  to  the  contradictory  testimony  of  the  different  author- 
ities, and  the  absence  of  pathological  information,  we  must 
form  our  opinion  from  the  general  condition  of  the  urine.  If 
the  urea  and  phosphoric  acid  are  not  largely  in  excess  of  normal, 


492  THE  DISEASES  OF  CHILDREN. 

the  patient  being  well  cared  for  and  without  hereditary  taint^ 
it  is  possible  that  he  may  live  as  long  as  otherwise.  If,  on  the 
other  hand,  there  is  marked  increase  of  urea  and  phosphoric  acid, 
suspect  the  condition  to  be  but  a  prelude  to  serious  constitu- 
tional disturbance,  and  give  ultimately  unfavorable  prognosis. 
In  some  cases  nervous  disorder  or  phthisis  appears  ;  in  others, 
diabetes  mellitus.  Albuminuria  is  an  unfavorable  sign,  as  is 
also  edema  of  the  feet.  In  one  case  which  I  saw,  apparently 
congenital,  at  the  age  of  sixteen  I  found  albumin ;  two  years 
later  casts  appeared,  the  patient  became  more  or  less  edema- 
tous, and  died  of  uremia.  Children  may  succumb  to  exhaustion 
caused  by  loss  of  rest,  tormenting  thirst,  and  mental  worry. 

Treatment. — Everything  which  aggravates  the  condition 
must  be  sought  for,  and  if  possible  removed  ;  inveterate  mas- 
turbation, enuresis,  even  tapeworm,  hereditary  syphilis,  must 
not  be  overlooked.  Phimosis  and  rectal  diseases  should  receive 
attention. 

When  the  patient  is  not  voiding  too  much  urea,  give  food 
and  drink  liberally,  seeing  to  it  that  drinks  are  not  too  cold. 
The  various  drinks  may  be  thickened,  as,  for  example,  by  the 
use  of  a  handful  of  raw  oatmeal  to  a  quart  of  boiling  water  with 
a  lemon  sliced  into  it.  Warm  woolens  should  be  worn,  and  the 
patient,  if  possible,  spend  winters  in  a  warm,  dry  climate.  Salt- 
water douches  are  sometimes  useful  in  promoting  bodily  vigor. 
Warm  baths,  followed  by  friction  of  the  skin  with  coarse  towels, 
are  beneficial. 

In  cases  where  urea  is  increased  relatively  to  the  weight  of 
the  patient,  nitrogenous  food  is  to  be  limited.  Alcoholic  drinks 
and  coffee  not  allowed.  Vapor  baths,  followed  by  salt-water 
tepid  douches,  are  recommended  and  a  dry,  bracing  climate 
sought.  Hygienic  care  and  regulations,  as  in  diabetes  mellitus, 
ordinary  warm  baths,  followed  by  friction  of  the  skin  with 
coarse  towels,  are  often  found  beneficial. 

Remedies. — Those  already  mentioned  under  diabetes  mellitus 
are  frequently  indicated  in  this  disorder. 

In  anemia  and  debility,  ferrum,  nux  vomica,  and  china; 
cod-liver  oil  and  the  iodide  of  iron  will  help  debilitated  children 
with  diabetes  insipidus.     In  syphilitic  cases,  iodide  of  sodium. 

Jum-bul  will  undoubtedly,  in  some  cases,  decrease  the  quan- 
tity of  urine ;  but  its  action  is  at  best  but  imperfectly  under- 
stood, and  it  is  said  not  to  be  efificacious  with  the  patient  on 
a  mixed  diet. 

Helenin  will  be  indicated  in  some  cases. 

Apocynum  is  said  to  be  useful  for  the  well-known  "  sinking 
sensation"  at  the  stomach. 

Strychnia,  in  one-grain  doses  of  the  third  decimal  trituration, 


URINE  IN  DIABETES  INSIPIDUS.  493 

possibly  increased  in  time  to  the  second  decimal,  is  of  use  in 
combating  the  various  nervous  symptoms. 

Sodium  bromide  is  believed  by  Purdy  to  have  arrested  two 
cases ;  he  thinks  that  the  drug  should  be  given  in  doses  large 
enough  to  affect  locomotion,  and  then  decreased  to  a  point  just 
short  of  affecting  it.  In  some  cases  the  constant  galvanic  cur- 
rent has  been  found  beneficial.  Purdy  says  that  the  best 
results  are  said  to  follow  the  application  of  the  positive  pole  to 
the  cervical  region  over  the  vertebra,  and  the  negative  pole  to 
the  lumbar  region  and  pit  of  the  stomach,  alternately. 

Ergot  appears  to  have  cured  some  cases.  The  doses  recom- 
mended are  60  to  120  minims  of  the  fluid  extract  for  an  adult. 

Miscellaneous. — Claims  are  made  by  the  older  school  of  cures 
by  the  following  agents :  Potassium  iodide  and  mercury  (dose 
not  given)  reduced  the  urine  of  a  child  of  six  from  30  pints  to 
4  (Demme) ;  combined  use  oi  antipyrin,  o.^  gram  (7^  grains) 
three  times  daily,  powdered  valerian  root  three  times  daily, 
and  galvanism  to  the  cervical  sympathetic  and  to  the  spine, 
cured  a  case  in  a  boy  of  twelve  years,  who  voided  13700  c.  c. 
in  twenty-four  hours,  with  specific  gravity  less  than  looi 
(Zeuner). 


CHAPTER  X. 

ENURESIS. 

Definition  and  Synonyms. — Involuntary  emission  of  urine; 
incontinence,  of  urine.  Enuresis  nocturna,  incontinence  of 
urine  at  night ;  enuresis  diurna,  incontinence  of  urine  during 
the  day;  enuresis  continua,  incontinence  of  urine  both  during 
day  and  at  night. 

Etiology  and  Pathology. — In  a  large  number  of  cases  the  cause 
is  persistence  of  infantile  weakness  in  the  neck  of  the  bladder — 
incompetence  of  the  sphincter.  In  another  series  of  cases,  in- 
creased reflex  irritability  of  the  bladder  is  the  cause,  compli- 
cated or  uncomplicated  with  the  above  described  incompetency 
of  the  sphincter,  and  depending  either  on  the  bladder  itself  or  due 
to  some  outside  cause  (Jacobi).  Some  of  these  causes  of  irri- 
tability are  as  follows :  fissure  of  the  neck  of  the  bladder,  vesi- 
cal calculus  ;  increased  irritability  of  the  bladder  from  unknown 
cause ;  increased  quantity  of  urine,  as  in  diabetes,  nephritis,  or 
from  increased  ingestion  of  water;  irritant  nature  of  the  urine 
from  hyperacidity,  hyperalkalinity,  or  drugs,  including  salines, 
chlorides,  and  chlorates ;  anal  irritation  from  pin-worms,  fissure, 
eczema,  etc. ;  hyperesthetic  state  of  the  external  genitals  de- 
pendent on  stricture,  phimosis,  balanitis,  etc. ;  the  psychical 
influence  of  dream  impression.  Unconscious  micturition  may 
also  be  due  to  general  debility,  spinal  disease,  injuries  and  dis- 
eases of  the  spinal  cord,  diseases  of  the  vesical  nervous  supply, 
and  acute  febrile  diseases.  In  some  cases  the  complication  of 
enuresis  with  general  muscular  insufficiency  is  very  marked. 
Masturbation  is  said  in  the  young  to  lead  to  chronic  inflamma- 
tion of  the  whole  prostatic  portion  and  the  neck  of  the  bladder, 
which  is  then  very  sensitive ;  hence  incontinence  of  urine  may 
sometimes  be  due  to  this  habit.  Cystitis  adds  to  the  irritabil- 
ity of  the  detrusor  muscles  and  is  a  frequent  cause  of  inconti- 
nence, when  this  makes  its  appearance  in  children  whose 
micturition  was  normal  before  (Jacobi). 

Pyelitis  and  vaginal  catarrh  are  also  to  be  included  in  the 
etiology. 

Taylor's  classification  of  the  causes  of  enuresis  is  as  follows  : 
mechanical,  diathetic,  reflex. 

Mechanical C2MSQS  are  adherent  folds  of  mucous  membrane 
(494) 


ENURESIS.  495 

in  and  about  the  genitals  ;  mechanical  irritation  of  foreign 
bodies,  as  seat-worms.  Small  polypoid  excrescences  at  the 
neck  of  the  bladder  in  very  young  girls  have  been  found  by 
Jacobi. 

Diathetic  causes:  Uricemia  is  often  found  after  over-fatigue 
in  play  or  excitement,  or  manifested  by  tonsilitis  or  several 
forms  of  pharyngeal  irritation,  or  by  sediment  of  uric  acid  in 
the  urine.  Phosphatic  urine  or  urine  alkaline  from  fixed  alka- 
lies is  to  be  reckoned  among  these  causes. 

Reflex  causes  may  be  a  combination  of  mechanical  and 
diathetic,  or  a  result  of  emotion,  habits,  instability  of  nervous 
balance. 

Slight  palsies  should  be  searched  for.  Taylor  believes  that 
enuresis  is  often  found  in  children  in  whom  slight  hemiplegias 
with  descending  degenerations  had  occurred. 

Insufficient  innervation,  as  in  the  case  of  slow,  dull,  stupid 
children,  is  a  cause. 

Mouth-breathing  children  may  have  incontinence  due  to  slow 
carbonic-acid  poisoning. 

Krauss  divides  the  causes  of  enuresis  into  four  groups :  First, 
functional  disturbances  of  the  genito-urinary  organs  causing 
irritation,  as  tight  prepuce,  irritable  clitoris,  narrow  meatus, 
sensitive  urethra,  weak  sphincter,  cystitis,  due  to  pressure  on 
bladder  in  pregnancy,  and  ascarides  in  the  rectum  ;  second, 
cerebral  nervous  disorders,  precocious  and  pernicious  mental 
development,  and  dreams ;  third,  failure  of  spinal  reflex,  as  in 
locomotor-ataxia,  transverse  myelitis,  tumors  of  the  cord ;  fourth, 
organic  changes  in  the  genito-urinary  tract. 

Van  Tienhoven  believes  the  exciting  cause  of  nocturnal  enu- 
resis in  boys  to  be  the  incomplete  closure  of  the  prostatic 
urethra,  during  the  general  muscular  relaxation  of  sleep.  The 
urine  collecting  in  the  bladder  soon  finds  its  way  into  the 
urethral  pouch  and  gives  rise  by  its  presence  to  reflex  detrusor 
spasm. 

Kupke  thinks  it  possible  that  incontinence  is  often  the  result 
of  a  weakness  on  the  part  of  the  spinal  cord,  which  loses  its 
power  to  transmit  to  the  brain  the  impression  of  distention  in 
the  bladder.  On  the  other  hand,  we  must  admit  that  an  anes- 
thetic condition  of  the  sensitive  nerves  of  the  bladder  can 
occur,  by  reason  of  which  the  micturition  center  in  the  spinal 
cord  is  only  feebly  made  aware  of  the  need  to  urinate.  Weak- 
ness of  the  bladder,  from  general  debility  or  anemia,  is  a  very 
common  cause ;  the  bladder,  not  being  able  to  tolerate  any 
quantity  of  urine,  readily  excites  the  motor  apparatus.  A  case 
of  the  kind  has  been  known  to  follow  typhoid  fever. 

Hysterical  children  may  have  nocturnal  incontinence.     Ac- 


496  THE  DISEASES  OF  CHILDREN. 

cording  to  Trousseau,  the  first  cause  of  incontinence  is  a  neu- 
ropathic disposition.  If  periodicity  of  incontinence  is  a  marked 
element  in  it,  then  the  condition  is  nervous  in  origin. 

Incontinence  may  accompany  severe  nocturnal  epilepsy  and 
in  all  obscure  cases  possibility  of  the  latter  should  not  be  over- 
looked.    It  also  may  accompany  night  terrors. 

Bobulescu  saw  two  cases,  four  and  five  years  old  respectively, 
in  which  the  incontinence  was  dependent  upon  splenic  hyper- 
trophy. 

It  is  now  held  that  certain  cases  of  incontinence  in  boys  dis- 
appear with  growth  and  development  of  the  prostate,  which  is 
properly  a  muscle  and  not  a  gland. 

Diurnal. — Incontinence  of  children  is  thought  by  some  au- 
thors to  depend  on  inordinate  and  uncontrollable  contraction 
of  the  bladder,  hence,  sometimes  denominated  chorea  of  the 
bladder.  Oberlander  thinks  it  due  only  to  refllex  irritation  in 
the  urethral  and  anal  openings.  Fauboren  says  the  cause  is  in- 
suflficiency  of  the  sphincter  vesica,  which  permits  a  little  urine  to 
enter  the  upper  portion  of  the  urethra,  and  its  presence  there 
causes  a  further  performance  of  the  act  by  the  excitation  of  re- 
flex contraction.  Enuresis  is  attributed  by  some  to  a  lack  of 
power  of  retention,  and  enfeeblement  of  the  voluntary  power 
of  the  sphincter  at  the  neck  of  the  bladder  and  commencement 
of  the  urethra. 

Bissell  thinks  daytime  enuresis  due  most  commonly  to  some 
constitutional  or  general  cause.  It  is  found  in  children  who  are 
bright,  cheerful,  active,  hypersensitive,  or  dull,  stupid,  and 
slow  in  mind  and  muscles.  It  may  also  be  due  to  some  local 
disturbance  or  irritation,  or  phimosis,  worms  in  the  vulva,  va- 
gina or  rectum,  inflammation  of  bladder  and  urethra,  stone, 
growths,  etc. 

EXAMINATION    OF    EATIENT. 

1.  Examine  the  rectum  ;  look  for  pin-worms,  fissure,  eczema. 
Inquire  whether  constipation  is  present  or  not. 

2.  Examine  the  external  genitals ;  look  for  phimosis,  adher- 
ent folds  of  mucous  membrane  in  and  about  the  genitals,  sen- 
sitive clitoris,  tight  prepuce,  narrow  meatus ;  hypersensitive 
condition  of  the  vagina,  vestibule  and  urethra  in  girls,  points 
to  masturbation  as  a  cause  ;*  enlarged  penis  and  scrotum  in  boys, 
together  with  general  malaise,  dull  headaches,  alteration  of 
temper  and  somnolence,  are  due  to  same  cause.  It  is  needless 
to  say,  however,  that  catching  the  child  in  the  act  is  the  surest 


*See  also  article  on  "  Diagnosis  of  Masturbation." 


ENURESIS— EXAMINATION  OF  PATIENT.  497 

means  for  diagnosis  of  this  habit.  Look  for  balanitis,  vulvitis, 
stricture  of  the  urethra,  urethritis,  sensitive  urethra,  excres- 
cences about  the  meatus  urinarius  in  girls.  Vaginal  catarrh 
must  not  be  forgotten.  Possibility  of  retention  in  the  bladder 
should  not  be  overlooked. 

3.  In  case  nothing  be  found  by  examination  as  above,  collect 
';he  twenty-four  hours'  urine,  examine  it,  and  also  a  freshly- 
voided  specimen  ;  the  night  urine  may  be  saved  either  by  the 
devices  already  mentioned  in  case  of  young  children,  or  by  use 
of  a  rubber  urinal  in  older  ones. 

The  points  to  be  sought  for  in  the  examination  of  urine  are 
presence  of  cystitis,  pyelitis,  nephritis,  or  diabetes  ;  or,  if  these 
are  absent,  effort  should  be  made  to  ascertain  whether  or  not 
there  is  increased  acidity,  whether  uric-acid  crystals,  calcic  oxa- 
late, triple  phosphate,  or  even  simple  phosphates  (earthy)  are 
present. 

4.  If  the  condition  of  the  urine  shows  nothing,  look  for  mal- 
formations of  the  urethra  and  bladder,  and  for  stone  in  the 
bladder. 

5.  Still  further,  if  nothing  thus  far  has  been  found  as  a  cause, 
consider  muscular  weakness  of  the  bladder  due  to  general  de- 
bility, anemia  ;  inquire  for  history  of  recent  severe  illness,  as 
typhoid.  Investigate  the  possibility  of  spinal  disease,  and  look 
carefully  for  slight  palsies.  Nocturnal  epilepsy  must  not  be 
forgotten,  and  mouth-breathing  looked  after. 

6.  Even  if  no  signs  of  uricemia  be  present  in  the  urine,  ex- 
amine patient  for  presence  of  tonsilitis  or  pharyngeal  irritation, 
and  if  found,  examine  urine  frequently  for  evidences  of  urice- 
mia, especially  that  voided  after  over-fatigue  at  play. 

7.  Next  inquire  for  psychical  causes  ;  ask  the  child  if  he 
dreams  that  he  wants  to  urinate,  or  that  he  is  urinating.  Ob- 
serve whether  the  child  is  intensely  somnolent,  unbalanced,  etc., 
etc.  Ascertain  wh^Xh^r  periodicity  of  incontinence  is  a  marked 
feature  ;  if  so,  the  case  is  of  nervous  origin. 

Treatment. — Enuresis  dependent  upon  the  conditions  enu- 
merated one  to  five,  will  yield  only  to  successful  treatment  of 
the  disorders  to  which  it  is  secondary.  Rectal  diseases  re- 
quire attention  from  an  orificialist.  In  cases  due  to  phimosis, 
circumcision,  as  an  extreme  measure  and  only  when  absolutely 
necessary,  should  be  performed  when  the  prepuce  is  adherent ; 
it  is  generally  sufificient  to  break  up  the  adhesions  by  stretch- 
ing the  prepuce  and  removing  the  smegma. 

Taylor  describes  his  method  of  stripping  adhesions  as  follows: 

"  I   take  a  blunt-pointed  probe,  or  similar  instrument,  and 

cautiously  run  it   around   over  the  head  of  the  glans  from  the 

frenum  on  one  side,  by  small  circular  motions,  to  the  frenum  on 

D.  C— 32 


498  THE  DISEASES  OF  CHILDREN. 

the  other,  and  then  advancing  the  point  of  the  probe  again  ro- 
tate back  to  the  first  point  to  the  right,  and  then  over  to  the 
left,  until  gradually  I  have  broken  up  the  adhesions  under  the 
foreskin,  and  then,  when  this  is  done,  I  introduce  into  the  cav- 
ity thus  formed  some  lubricant,  and  make  sure  of  its  proper 
distribution.  Afterwards  the  foreskin  may  be  gently  retracted ; 
but  if  the  opening  be  small,  I  postpone  this  for  a  day  or  two, 
when,  again  running  the  probe  back  and  forth  over  the  glans, 
very  likely  the  foreskin  can  be  retracted.  Failing,  I  wait  a  few 
days  longer,  and  if  the  os  still  be  very  constricted,  I  gently 
stretch  it  by  some  suitable  instrument,  as  a  pair  of  dressing  for- 
ceps, and  thus  gradually  secure  my  purpose.  The  mother  is 
carefully  instructed  to  wait  a  certain  length  of  time  after  my  ma- 
nipulations, and  then  herself  to  retract,  wash,  and  reanoint  the 
parts  ;  to  be  done  at  intervals  of  two  or  three  days.  A  more 
rapid  stripping  may  be  safely  done,  but  in  the  manner  described 
everything  needed  is  usually  accomplished,  and  with  the  mini- 
mum of  pain  and  discomfort  to  the  child  and  of  alarm  to  the 
mother,  always  an  important  consideration. 

"  In  little  girls,  irritations  about  the  vagina  must  be  looked 
for  in  the  same  way,  although  occurring  less  frequently.  The 
prepuce  of  the  clitoris  is  not  seldom  adherent,  just  as  occurs  in 
boys.  The  process  of  relieving  it  is  very  much  easier  in  the 
girls,  however,  and  yet  of  quite  equal  importance.  It  may 
sometimes  be  necessary  in  these  procedures  to  use  a  little  co- 
caine locally,  but  it  is  well  to  bear  in  mind  that  this  is  a  very 
dangerous  measure." 

If  there  is  balanitis,  the  remedies  are  tnerc.  cor.y  mere,  sol., 
thuja,  and  local  applications,  as  calendula  ;  in  valvitis,  arseni- 
cum,  thuja,  mercurius. 

Cases  due  to  masturbation  or  nervous  diseases  belong  under 
consideration  of  the  treatment  of  the  latter  disorders. 

For  incontinence  referable  to  uricemia  (lithemia),  see  treat- 
ment under  heading  Uricemia.  Diet  and  the  benzoates  are  use- 
ful when  uricemia  is  a  cause. 

When  the  cases  are  dependent  upon  irritability  of  the  blad- 
der, belladonna,  in  lo  to  20  drop  doses  of  the  tincture,  or  atro- 
pinesulphate,  one  grain  in  an  ounce  of  water,  given  in  doses  of 
one  drop  for  each  year  of  the  child,  at  four  and  at  seven  even- 
ings, so  as  to  have  the  pupils  dilated  during  hours  of  sleep. 
The  dose  at  bedtime  need  not  be  given  if  the  child's  pupils  are 
well  dilated,  and  in  the  case  of  small,  feeble  children,  great  care 
must  be  taken  in  giving  atropin.  Moreover,  atropin  is  not  a 
specific. 

In  cases  apparently  due  to  lack  of  tone  in  the  sphincter,  rhus 
aromatica  is  certainly  of  service  ;  dose  from  4  to  10  drops  of 


ENURESIS— TREATMENT.  499 

the  fluid  extract  four  times  daily,  gradually  increased  to  from 
8  to  20  or  30  drops,  according  to  age  of  child.  If  given  in  too 
large  doses  at  first,  it  may  disturb  the  digestion.  Children  two 
to  six  years  old  may  take  10  drops  night  and  morning,  other 
children  15  drops.  Its  favorable  effects  may  not  persist.  In 
one  of  my  cases  the  child  did  not  wet  the  bed  in  those  nights 
in  which  he  took  30  drops  before  going  to  bed  ;  in  nights  when 
he  did  not  take  the  remedy  he  infallibly  wet  the  bed. 

Ferrufn  muriaticum  has  been  recommended ;  2  drops  of 
liquor  ferri  muriatici  in  a  wine-glass  full  of  water,  tablespoonful 
every  three  hours  during  the  day.*  Gelsemium,  equisetum, 
eupatorium, Pulsatilla  are  credited  with  cures. 

In  cases  of  atony  of  the  sphincter,  electricity  is  advised. 
Ultzmann  held  that  the  best  treatment  is  indirect  stimulation 
of  the  sphincter  through  the  rectum.  He  used  the  ordinary 
Dubois-Reymond  sledge-battery,  armed  with  one  element.  One 
pole  of  the  induced  current  is  a  metallic  pin  the  size  of  a  lead 
pencil,  and  seven  centimetres  long,  with  a  wooden  handle ;  the 
pencil,  being  well  oiled,  is  passed  into  the  rectum.  The  other 
pole  is  an  ordinary  sponge-holder,  which,  in  boys,  is  placed  on 
the  raphe  of  the  perineum,  but  in  girls  in  the  crease  of  the  but- 
tock. The  current  at  first  must  be  very  weak  and  gradually 
increased.  Sittings  to  be  held  daily,  or  every  other  day,  and  to 
last  five  to  ten  minutes.     Treatment  lasts  four  or  five  weeks. 

In  spinal  cases  nux  vomica  or  strychnin,  third  to  sixth  deci- 
mal according  to  age.  In  hysterical  children,  the  valerianates, 
bromides,  etc. 

Tincture  of  equisetum  may  be  given  as  follows :  one  drachm 
to  four  fluidounces  of  water,  two  teaspoonfuls  every  three  hours. 
If  there  is  constipation,  give  enema  of  soap  and  water  before 
going  to  bed,  and  after  the  bowels  have  moved  place  supposi- 
tory of  one  grain  of  belladonna  in  the  rectum.  If  for  any  cause 
diurnal  incontinence  take  place,  it  should  be  inserted  night  and 
morning  both.  Abstinence  from  meat  and  liquids  at  night 
should  be  enjoined,  and  five-grain  doses  of  benzoic  acid  given 
three  times  daily  when  the  urine  is  hyper-acid. 

Cold  sponging  night  and  morning  is  often  beneficial  as  an 
adjuvant. 

Miscellaneous  Notes  on  Treatment. — In  the  Hahnemannian 
for  July,  1893,  Dr.  Goodno  describes  two  cases  as  follows: 

"  Some  months  since  Dr.  Myers  called  my  attention  to  the 
value  of  equisetum  as  a  remedy  for  nocturnal  enuresis,  stating 
that  he  had  treated  several  cases  successfully.  Having  had 
two  cases  on  hand  for  about  four  and  six  years  respectively, 


•See  MitchelPs  "  Diseases  of  the  Kidneys,"  page  366. 


600  THE  DISEASES  OF  CHILDREN. 

and  treatment  not  having  been  attended  by  any  substantial 
benefit,  I  decided  to  make  use  of  it. 

"  Case  I.  was  a  boy,  aged  thirteen  years,  who  came  under  my 
care  when  he  was  seven  years  old,  and  whom  I  have  treated 
intermittingly  ever  since.  He  has  regularly,  each  night,  satur- 
ated his  bed,  with  rare  exception,  since  he  was  a  baby.  Had 
given  many  remedies,  performed  circumcision,  and  applied  a 
variety  of  '  methods '  with  almost  no  result.  There  was  no 
incontinence  during  the  day.  Equis.  o  gtt.  x  three  times  daily 
arrested  his  disease  at  once.  During  the  first  three  weeks  of 
trial  a  mishap  occurred  only  twice.  During  the  next  three 
weeks  it  occurred  five  times,  but  four  were  after  his  medicine 
had  given  out.  The  past  month  he  has  had  15  to  20  drops  of 
o  three  times  daily,  and  has  had  only  two  errors.  While  this 
boy  is  not  cured,  it  must  be  confessed  he  is  making  great  strides 
toward  a  favorable  result. 

"  The  second  case  is  that  of  a  little  girl  seven  years  of  age, 
who  has,  like  the  boy,  had  incontinence  since  babyhood,  but, 
unlike  him,  her  trouble  has  been  diurnal  as  well  as  nocturnal. 
Most  days  she  wet  herself  two  or  three  times  daily.  She  is  a 
very  nervous  child  ;  indeed,  has  positive  hysteria,  indicated  by 
the  globus  hystericus,  and  a  wide  range  of  hysterical  symptoms. 
At  times  there  has  been  a  little  improvement  from  remedies, 
but  never  any  marked  change  until  I  gave  her  valerianate  of 
ammonia,  in  grain  doses,  four  times  daily.  This  remedy  not 
only  helped  her  hysterical  condition,  but  she  would  go  a  week 
without  any  mishap  during  the  day,  and  miss,  perhaps,  every 
other  night.  After  a  time  it  failed  to  accomplish  anything, 
and  I  gave  it  up  after  varying  the  dose  considerably.  Equise- 
tum  o  gtt.  v.,  three  times  daily,  arrested  the  whole  trouble 
immediately ;  not  a  single  mishap  occurred,  day  or  night,  for  a 
week.  Since  that  time  the  child  has  occasionally  wet  herself, 
both  at  night  and  during  the  day,  but  the  errors  have  been 
rare. 

Dr.  Van  Baum  writes  me  that  he  has  not  had  flattering  suc- 
cess from  use  of  equisetum.  Personally  I  have  had  no  experi- 
ence with  it  worth  mentioning. 

Liebault  has  cured  nocturnal  incontinence  in  hysterical,  or 
at  least  neurotic,  children,  by  hypnotic  suggestion. 

F.  C.  Simpson  has  seen  a  number  a  cases  which,  treated  with 
every  possible  care  and  with  every  drug  known,  still  continue 
to  wet  the  clothing,  though  not  the  bed  at  night.  In  his  opin- 
ion, these  cases  are  referable  to  masturbation,  and  he  has  cured 
a  number  by  blistering  the  penis. 

Overpeck,  in  the  Pulte  Quarterly,  reports  four  cases  as  follows : 

"  I.  The  young  man  is  well  nourished,  has  a  fair  skin,  blue 


EN  URESIS—  TREA  TMEN  T.  501 

eyes,  and  brown  hair.  Is  restless  in  his  sleep,  but  hard  to  waken. 
Feet  are  always  damp  from  perspiration.  Is  very  fond  of 
sweet  things.  Has  no  trouble  with  urine  except  at  night. 
Gave  sulphur. 

"  2.  The  sister  is  similarly  organized,  and  the  description 
above  will  apply  to  her  with  these  few  exceptions :  Hands 
are  always  cold.  She  sleeps  quietly,  and  has  this  symptom 
which  is  so  characteristic  of  the  remedy  she  received :  frequent 
and  very  urgent  calls  to  urinate  during  the  day,  and  these  more 
frequent  when  at  rest  than  when  exercising.  Who  would  not 
say  rhus  tox.? 

"They  began  by  taking  the  medicine  in  the  sixth  dilution  six 
times  per  day,  the  interval  afterward  being  gradually  length- 
ened, and  the  attenuation  raised  to  the  two  hundredth.  After 
taking  these  for  five  or  six  months,  a  letter  informs  me  that  the 
son  is  entirely  well,  and  has  been  away  from  home  on  a  vaca- 
tion trip,  which  is  the  first  in  his  lifetime.  The  sister  is  pro- 
nounced about  cured. 

"  3.  A  boy  of  five  years,  rather  thin,  abdomen  large.  Cervi- 
cal glands  are  slightly  enlarged  at  times.  Urinates  frequently, 
and  that  passed  involuntarily  at  night  is  very  offensive  and 
profuse.  He  is  particularly  fond  of  sweets,  and  at  times  has 
indications  of  the  presence  of  stomach  worms.  He  has  been 
doctored  by  a  *  regular,'  and  finally  circumcised,  all  to  no  pur- 
pose. In  this  case  I  gave  calc.  carb.,  with  occasionally  a  few 
powders  of  santonin,  then  followed  these  with  sulphur.  This 
may  not  have  been  scientific  prescribing,  but  it  did  the  work  in 
a  few  weeks. 

"  4.  Boy  of  three  years,  subject  to  epileptic  attacks.  Has  a 
large  head.  Was  slow  in  teething  and  walking,  and  had  eczema 
on  face  and  scalp.  Calc.  carb.  has  cured  the  urinary  weakness, 
and  the  general  condition  of  the  patient  is  much  improved." 

Dr.  Sereno  used  electricity  in  the  case  of  an  unmarried 
woman  who  had  had  enuresis  from  childhood.  The  interrupted 
current  was  employed  with  a  large  wire.  One  pole  in  the  form 
of  a  plate  was  applied  over  the  abdomen,  and  the  other  brought 
into  contract  with  the  sphincter  of  the  bladder  by  means  of  a 
vesical  sound.  The  current  was  of  supportable  intensity  and 
was  applied  for  five  minutes  three  times  a  week.  After  eight 
sittings  the  patient  wetted  her  bed  only  one  night  out  of  every 
two  and  retained  her  urine  very  well  during  the  day.  A  com- 
plete cure  is  expected. 

Aldrich,  of  Minneapolis,  cites  a  case  of  a  girl  of  six  in  which 
albumin  was  found,  which  disappeared  when  rectal  and  biman- 
ual massage  had  restored  the  pelvic  organs  to  their  normal  tone. 
He  thinks  well  of  massage  of  the  bladder  per  rectum,  together 


502  THE  DISEASES  OF  CHILDREN. 

with  a  daily  salt-water  bath,  accompanied  by  brief  rubbing 
in  the  region  of  the  spine,  with  attention  to  hygiene,  diet,  and 
psychical  surroundings. 

In  the  treatment  of  enuresis,  Taylor  suggests  as  an  adjuvant 
that  the  bed  be  tilted,  so  that  the  child  may  lie  with  heels  high 
and  head  low.  An  admirable  rule  is  that  the  bowel  be  thor- 
oughly cleansed  by  an  enema  a  short  time  before  going  to  bed. 
The  following  remedies  have  been  useful  in  certain  cases : 

Hyoscin  hydrobromate,  in  doses  systematically  increased  until 
certain  disagreeable  symptoms,  as  over-dryness  of  the  throat 
and  nose,  and  dimming  of  vision,  are  observed.  In  many  cases, 
desirable  results  are  obtained  before  these  symptoms  appear. 
Cantharides  in  small  doses  slowly  and  cautiously  increased,  may 
be  given  at  the  same  time.  Phosphate  of  sodium,  if  there  are 
digestive  disturbances.  Circumcision  is  an  extreme  measure, 
although  at  times  a  proper  one.  Taylor  thinks  it  quite  suffi- 
cient to  strip  the  parts  thoroughly,  making  sure  that  readhesions 
do  not  occur. 

Milk  diet  is  advised  during  treatment. 

H.  A.  Husband  in  the  Canada  Lancet  reports  the  following: 
"The  case  was  that  of  a  boy,  aged  19  years,  the  eldest  of  four 
sons,  all  of  whom  had  been  troubled  with  the  same  complaint 
since  birth.  The  patient  had  at  various  times  been  treated 
with  tincture  of  belladonna,  but  with  no  apparent  benefit.  It 
was  found  that  the  boy  suffered  from  chronic  constipation, 
which  was  relieved  by  a  pill  of  extract  of  rhubarb  and  nux 
vomica,  given  night  and  morning. 

"  The  lower  bowel  was  washed  out  every  night  with  an 
enema  of  warm  soap  and  water,  and  then  a  suppository  con- 
taining one  grain  of  belladonna  placed  in  the  rectum.  The 
object  of  the  enema  was  to  clear  out  any  hardened  feces  or 
thread-worms,  which,  by  their  presence,  might  by  their  irritation 
produce  the  incontinence.  This  treatment  was  rigidly  contin- 
ued for  three  months  with  some  slight  benefit,  a  week  or  two 
passing  without  a  return  of  the  complaint.  The  amount  of 
belladonna  was  now  increased  to  a  grain  and  a  half.  And  then 
a  new  symptom  made  its  appearance.  The  nocturnal  incon- 
tinence ceased,  but  the  patient  during  the  day  became  troubled 
with  a  constant  desire  to  pass  water,  the  annoyance  being  so 
great  that  he  had  to  micturate  every  five  minutes.  The  sup- 
pository was  then  ordered  to  be  used  night  and  morning,  with 
the  entire  discontinuance  of  the  nocturnal  and  diurnal  trouble. 
During  the  last  three  months  the  pupils  became  permanently 
dilated,  but  there  was  no  irritation  of  the  skin,  and  only  occa- 
sionally slight  dryness  of  the  throat.  In  six  months  a  complaint 
which  had  lasted  nineteen  years  was  completely  cured,  and  the 


ENURESIS— TREATMENT.  508 

patient  was  enabled  to  proceed  to  the  continent  on  his  busi- 
ness, taking  with  him  a  mixture  containing  nitro-muriatic  acid, 
strychnin,  and  gentian.  The  conclusions  drawn  from  the  above 
case  are  these,  that  of  all  preparations  of  belladonna  the  extract 
is  the  best  ;  that  the  success  in  treatment,  to  a  great  extent, 
depends  on  the  clearing  of  the  rectum  of  its  contents,  and  the 
application  of  the  belladonna  as  near  the  bladder  as  possible ; 
and  that  partial  success  at  first  is  no  reason  to  discontinue  the 
treatment  in  despair." 

Dr.  Day  *  in  the  British  Medical  Journal  speaks  as  follows 
in  regard  to  enuresis  : 

"  Enuresis  is  sometimes  seen  in  connection  with  chronic 
albuminuria,  and  is  occasionally  so  persistent  as  to  require 
special  treatment.  It  seems  impossible  to  lay  down  a  plan  of 
treatment  for  general  adoption  ;  the  peculiarities  of  constitution 
and  habits  of  life  must  be  taken  into  consideration,  and 
hap-hazard  treatment  guarded  against.  Some  cases  are  cured 
or  relieved  by  the  combined  influence  of  electricity,  iron,  and 
belladonna.  The  successful  issue  is  in  a  great  measure  attrib- 
utable to  the  constant  care  which  the  mother  takes  in  feeding 
the  child  and  rigorously  attending  to  the  physician's  instruc- 
tions. Those  cases  that  date  from  birth  or  have  lasted  upwards 
of  a  year  are  invariably  intractable  and  often  incurable,  espe- 
cially if  the  child  be  of  nervous  parentage,  or  was  delicate  when 
born,  or  passes  large  quantities  of  urine.  With  respect  to  the 
utility  of  faradism  there  can  be  no  question  ;  it  requires  to  be 
used  regularly,  and  to  be  continued  for  a  considerable  time, 
but  it  sometimes  fails  altogether.  When  the  nervous  system  is 
weak,  and  there  is  general  debility,  the  sphincter  loses  its 
power,  and  urine  escapes  by  night  and  day  without  the  child's 
knowledge.  It  is  in  such  cases  as  these  that  iron  and  nux 
vomica  are  of  service. 

"  If  there  be  excess  of  muscular  action,  and  the  child  have 
frequent  inclination  without  power  to  control,  belladonna  is  an 
admirable  remedy.  It  occupies  a  prominent  place  as  a  thera- 
peutic agent,  and  sometimes  when  combined  with  iron,  even  in 
small  doses,  it  seems  to  do  good  ;  but  it  should  not  be  given 
up  in  obstinate  cases,  till  either  soreness  of  the  throat  is  pro- 
duced or  dilatation  of  the  pupils  takes  place.  In  Dr.  Day's 
hands  it  has  often  failed  when  administered  in  any  form  or 
dose.  It  certainly  tends  to  lessen  irritability  of  the  bladder, 
and  should  always  have  a  fair  trial. 

"  Cold  sponging  in  the  morning  is  very  serviceable  in  cases  of 
enuresis  that  appear  to  have  their  origin  in  general  debility.  It 


*  Therapeutic  Gazette. 


504  THE  DISEASES  OF  CHILDREN. 

braces  up  the  nervous  system  and  is  a  powerful  tonic.  The  slight 
sensation  of  chilliness  soon  passes  away  without  leaving  any  de- 
pression if  vigorous  friction  with  a  towel  be  employed  for  a 
few  minutes.  In  a  case  under  Dr.  Day's  care  about  three  years 
ago,  the  cure  was  attributed  to  this  simple  measure  when  one 
remedy  after  another  had  failed.  The  vital  functions  are 
brought  into  a  healthier  state,  the  skin  acts  better,  and  the 
appetite  and  digestion  improve.  However  delicate  a  child  may 
be,  free  sponging  in  tepid  water,  folllowed  by  a  good  rubbing, 
is  of  great  value." 

Kupke  expresses  the  opinion  in  the  Allgetn.  Med.  Central 
Zeitung,  that  Guyon's  method  of  electrization  is  most  rational. 
This  consists  in  introducing  into  the  urethra,  as  far  as  the 
membranous  portion,  a  metallic  sound  to  which  an  electrode  is 
attached,  the  other  electrode  being  placed  over  the  pubes  or 
the  perineum.  The  electric  current  should  be  quite  weak  at 
first. 

Dr.  Sanger  has  found  good  effects  from  the  mechanical 
method  of  introducing  a  metallic  catheter  into  the  bladder  of 
female  children,  making  firm  pressure  backward  and  to  the 
sides  several  times  while  the  thumb  covers  the  aperture  of  the 
instrument.  Ten  to  twelve  sittings  are  said  to  be  usually  suffi- 
cient. Such  a  mode  of  treatment,it  seems  to  us,  should  not  be 
entered  upon  until  other  milder  and  safer  ones  have  been  tried. 
In  all  cases  we  should  try  the  effect  of  giving  but  little  fluid 
toward  evening,  taking  up  the  child  several  times  in  the  first 
part  of  the  night,  seeing  to  it  that  the  bed  is  a  firm  and  rather 
hard  one,  and  encouraging  the  child  as  much  as  possible  to 
avoid  sleeping  on  the  back.  If  these  fail,  it  might  be  advisable 
in  picked  cases  to  carry  out  the  suggestions  of  a  recent  corre- 
spondent in  The  Lancet.  His  remedy  is  the  birch-rod  applied 
before  the  child  is  put  to  bed,  not  as  a  punishment,  but  in  a 
true  scientific  spirit.  Six  is  the  regulation  number  of  strokes, 
and  they  are  to  be  put  on  where  they  will  do  the  most  good. 
After  the  third  stance  the  cure  is  complete.  The  rationale  of 
the  method  is  that  it  awakens  in  the  boy  (girls  should  be  spared 
the  indignity)  a  desire  to  avoid  wetting  the  bed ;  it  draws  the 
blood  to  the  surface  for  a  few  hours,  and  thus  relieves  the  pel- 
vic organs ;  it  stimulates  the  lumbar  center,  controlling  mictu- 
rition through  the  nerves  distributed  to  the  upper  gluteal 
region ;  and  it  prevents  the  patient  lying  on  his  back. 

Moral:  Spare  the  rod  and  spoil  the  bed,  says  the  Medical 
Record. 

Krauss  treats  enuresis  as  follows :  In  cases  due  to  irritation, 
as  tight  prepuce,  narrow  meatus,  etc.,  etc.,  the  cause  is  removed 
and  rhiis  arojnatica  given  in  five-drop  doses,  increased  to  twen- 


ENURESIS— TREATMENT.  505 

ty-five  drops,  four  times  daily.  In  cases  due  to  central  nervous 
disorders,  in  precocious  children,  for  example,  with  pernicious 
mental  development,  etc.,  he  gives  rhus  aromatica,  together 
with  the  remedy  for  the  nervous  element — nervous  tonics  or 
sedatives,  as  mix  vomica  or  the  bromides.  If,  in  addition, 
there  is  anemia,  he  advises  the  iodide  of  iron. 

In  enuresis  of  children.  Dr.  R.  B.  James  has  found  atropin 
often  effective,  so  long  as  its  administration  was  continued  in 
full  doses.  But  after  leaving  off  the  drug  the  patients  were  no 
better  than  before.  His  plan  was  as  follows  {Archives  of  Pe- 
diatrics, September,  1890):  A  solution  of  atropin  sulphate 
was  made,  of  which  one  teaspoonful  represented  one-hundredth 
of  a  grain  of  the  drug.  Of  this  solution,  for  the  first  night, 
each  child  had  one  teaspoonful  at  6  and  another  at  9  P.  M.,  and 
this  to  be  increased  by  one  teaspoonful  every  night  till  a  con- 
trolling dose  was  reached  for  each  case.  None  of  them  were 
benefited  by  less  than  four-hundredths  of  a  grain  at  night — that 
is,  two-hundredths  of  a  grain  at  6  and  two-hundredthsof  a  grain 
at  9  P.  M. — while  others  required  as  much  as  eight-hundredths 
of  a  grain  (divided  as  above) ;  one  case  was  given  as  much  as 
one-tenth  of  a  grain  at  night  without  showing  symptoms  of 
poisoning.  Nothing  short  of  the  quantity  that  produced  full 
physiological  effects  was  of  any  avail.  After  the  controlling 
dose  was  ascertained  for  each  case,  it  was  repeated  every  night 
for  about  one  month,  when  the  drug  was  withheld  altogether. 
It  was  found  that  many  of  the  cases  were  relieved,  while  others 
were  not  benefited.  Of  the  cases  completely  relieved,  the  en- 
uresis returned  in  all,  with  one  exception,  in  periods  ranging 
from  one  to  six  weeks.  The  case  that  was  cured  was  a  healthy 
boy  but  slightly  affected.  These  cases  were  kept  under  close 
observation  for  eight  months,  during  which  time  many  of  them 
would  go  without  the  drug,  or  on  reduced  doses,  from  one  to 
four  weeks  without  wetting  themselves.  But  sooner  or  later 
the  relapse  would  occur  and  at  the  end  of  the  eight  months, 
they  were  but  little  better  than  when  treatment  was  started. 

A  writer  in  the  Medical  Record  sums  up  the  treatment  of 
enuresis  by  the  older  school  as  follows  : 

"Attention  should  be  paid  to  the  skin  by  use  of  massage, 
sea-bathing,  alcohol  sponge-baths,  frictions  with  coarse  towel, 
etc.  Girls  from  six  to  twelve  years  of  age  or  over  are  most  in- 
tractable to  treatment,  and  often  there  is  no  use  expecting  to 
get  much  relief  until  lessons  and  books  are  absolutely  prohib- 
ited, and  outdoor  exercises  and  air  take  their  place.  Among 
drugs  the  principal  indication  is,  first,  general  tonics,  as  for  in- 
stance, syr.ferri  iodidi,  syr.  hypophos.,'w\th.  mix  vomica;  cod-liver 
oil,  tonic  doses  of  quinin,  and  arsenic  for  the  bodily  condition. 


506  THE  DISEASES  OF  CHILDREN. 

The  best  drug  for  the  local  effect  on  the  bladder-muscles  is 
belladonna,  but  it  must  be  given  until  dilatation  of  the  pupil  to 
a  considerable  extent  is  obtained  ;  the  effect  of  this  drug  must 
be  carefully  watched  and  the  patient  given  a  good  deal  of  atten- 
tion. Strychnin  is  a  drug  of  value  in  these  cases,  for  its  gen- 
eral effect  as  well  as  for  its  power  over  the  sphincter  vesica.  A 
suppository  containing  one-quarter  grain  nux  vomica  intro- 
duced three  or  four  times  daily  into  the  rectum  has  had  a  very 
good  result.  Ergot,  internally,  combined  with  belladonna  or 
strychnin,  answers  the  indications.  Rhus  tox,  in  repeated 
doses  of  a  quarter  of  a  grain  of  the  powdered  leaves,  is  said  to 
be  very  eflficacious.  The  electrical  current  has  been  recom- 
mended very  highly  by  German  authors  for  this  trouble.  It  is, 
of  course,  a  powerful  local  stimulant.  One  electrode  is  applied 
to  the  perineum,  the  other  to  the  hypogastrium  or  lumbar 
region.  I  hesitate  about  using  instruments  in  the  bladder  and 
urethra  unless  there  is  positive  evidence  of  bladder  or  urethral 
disease  or  of  foreign  body. 

"  Yet  the  skillful  and  careful  introduction  in  a  boy  of  a  steel 
sound  large  enough  to  dilate  the  deep  urethra  and  distend  the 
neck  of  the  bladder  will  often  assist  greatly  in  the  cure  of  incon- 
tinence. Ordinarily,  and  in  the  ordinary  way,  the  introduction 
of  a  sound  or  the  use  of  deep  injections  is  brutal,  and  likely  to 
do  a  great  deal  of  harm,  if  it  fortunately  does  not  set  up  a 
cystitis  or  urethritis  which  may  be  very  diflficult  to  cure.  The 
introduction  of  a  sound  when  necessary  may  have  to  be  done 
under  ether  or  chloroform. 

"  The  third  class  of  cases,  where  the  children  have  all  the 
muscles  active  and  healthy  except  those  of  the  bladder,  are 
most  puzzling.  Any  probable  tendency  to,  or  a  constitutional 
disease,  is  either  to  be  excluded  or  treated.  Very  often  these 
patients  are  troubled  with  no  other  ailments  but  this  one.  It 
may  have  begun  as  a  nocturnal  enuresis  and  continued  as  day- 
time incontinence.  The  sphincters  of  the  rectum  are  often 
irritable  and  untrustworthy,  complicating  the  bladder  trouble. 

"  The  remedies  mentioned  above  are  also  available  in  this 
class.  It  may  be  that,  following  a  long-continued  enuresis  from 
local  or  other  long-since  removed  cause,  the  bladder  has  become 
contracted  or  contractured.  If  so,  treatment  of  such  case  will 
be  long  and  tedious,  and  cure  will  depend  on  appreciation  of 
the  physicial  condition,  the  internal  remedies  above-mentioned, 
and  the  patience  of  the  surgeon  and  the  patient.  I  have  never 
seen  good  results  obtained  in  these  or  similar  contracted  blad- 
ders by  forcible  or  gradual  distention  by  means  of  hypostatic 
pressure. 

"The   muscles   of   the   bladder,   acting  very   like    muscles 


ENURESIS—  TREA  TMEN T.  507 

elsewhere  in  the  body,  become  strengthened  and  developed 
by  exercise.  Forcible  distention  is  a  dangerous  and  decidedly 
unsafe  method. 

"  In  those  patients  where  all  other  methods  have  produced 
little  result,  and  where  the  bladder  is  not  contracted,  continued 
washing  of  the  bladder  twice  daily  with  a  simple  salt  solution 
will  sometimes  restore  to  a  certain  degree,  if  not  completely, 
the  tonicity  of  the  vesical  muscles,  and  bring  about  a  cure. 
This  measure  is  not  always  practical,  and  is  attended  with  con- 
siderable risk,  which  may  be  reduced  to  a  minimum,  however, 
by  a  skillful  surgeon,  with  clean  catheters  and  hands  and  a 
tractable  patient. 

"  Occasionally  these  cases  get  well  spontaneously,  especially  as 
they  reach  the  period  of  puberty,  at  which  time  the  genito- 
urinary system  undergoes  rapid  changes  in  its  development." 


PARX    IX. 

DISEASES  OF  THE  RESPIRATORY  ORGANS. 


CHAPTER   I. 
GENERAL     CONSIDERATIONS. 

There  are  certain  peculiarities  of  the  respiratory  apparatus 
in  infancy  that  must  be  understood  in  order  to  properly  esti- 
mate the  signs  of  disease  in  this  most  important  part  of  the 
economy.  The  physiological  differences  in  the  respiratory 
function  between  the  child  and  the  adult  are  numerous,  and,  in 
some  respects,  they  are  very  marked. 

For  example,  the  rapidity  of  respiration  is  much  greater  in 
infancy,  and  somewhat  more  so  all  through  childhood,  than  it  is 
during  adolescence  or  maturity. 

At  birth  the  respirations  average  from  thirty-five  to  forty  per 
minute  —  a  rapidity  which  in  the  adult  would  cause  grave  ap- 
prehensions. There  is  not  the  same  regular  rhythmical  action 
in  early  life,  even  in  health,  that  is  maintained  later  on.  The 
respiratory  muscles,  like  those  of  other  parts  of  the  infant  body, 
work  spasmodically,  and  under  every  slight  disturbance  of  the 
sensory  nerve,  the  respirations  become  jerky  and  irregular. 
While  the  infant  cannot  yet  see,  hear,  smell,  nor  taste  to  any 
great  extent,  it  can  feel,  and  that  most  acutely. 

It  is  through  the  action  of  the  sensory  nerves  that  the  first 
breath  is  drawn,  and  for  a  long  time  thereafter  the  respirations 
are  easily  disturbed  by  reflex  irritation. 

Pauses  in  respiration  are  a  peculiar,  but  natural  feature  in 
childhood,  and  they  are  especially  marked  when  the  child  is 
crying.  Goodheart  points  out  what  we  regard  as  the  true 
explanation  of  this  peculiarity.  He  says  it  is  not  due  to  mus- 
cular weakness,  as  some  aver,  "but  to  the  as  yet  imperfect  edu- 
cation which  is  seen  in  all  the  muscles,  whether  of  speech  or 
of  voluntary  movement.  Hence,  also,  the  Cheyne-Stokes  type 
of  respiration,  which  is  a  paroxysmal  one.  Children  work  par- 
oxysmally,  whatever  the  movement  in  hand.  The  nervous  dis- 
charge takes  place,  and  then  comes  a  pause — another  discharge 
(508) 


GENERAL  CONSIDERATIONS.  509 

and  another  pause — and  so  on  ;  and  it  is  only  as  the  nerve  cen- 
ters reach  a  higher  state  of  training  that  the  discharges  are  so 
regulated  as  to  become  more  continuous."  The  "  Cheyne- 
Stokes  "  type  of  breathing,  to  which  reference  is  made  above, 
consists  of  a  series  of.  short,  but  gradually  lengthening  inspira- 
tions, culminating  in  a  deep-drawn  breath,  from  which  in  a 
descending  scale,  the  respiratory  movements  flutter  down  to  an 
elongated  pause.  This  type  of  respiration,  though  much  mod- 
ified and  its  sharper  characteristics  destroyed,  is  very  often 
seen  in  infants.  This  should  always  be  borne  in  mind  in  mak- 
ing physical  examinations  in  children,  for  this  disturbance  of 
rhythm  may  mean  little  or  much,  as  other  symptoms  are  present 
or  absent,  to  render  it  normal  or  abnormal.  The  breathing  is 
diaphragmatic  in  children,  and  it  is  sometimes  difficult  to  detect 
the  movement  of  the  upper  part  of  the  thorax  if  the  child  is 
breathing  naturally.  In  examining  a  child,  therefore,  it  is  nec- 
essary to  have  the  chest  thoroughly  bare,  so  that  every  move- 
ment of  the  respiratory  muscles  may  be  closely  observed.  For- 
cible movement  of  the  thoracic  walls  indicates  labored  breathing, 
and  is  always  present  in  broncho-pneumonia.  Great  recession 
of  the  lower  parts  of  the  chest  suggests  some  impediment  to 
the  entrance  of  air  into  the  lungs.  It  should  always  be  borne 
in  mind,  when  examining  an  infant  suspected  of  pulmonary 
disease,  either  acute  or  chronic,  that  the  lungs  may  never  have 
been  fully  expanded  since  birth ;  or  that  a  collapse  of  some 
portion  of  the  lung  may  have  occurred  as  the  result  of  obstruc- 
tion to  the  entrance  of  air  from  catarrhal  inflammation.  The 
possibility  of  a  considerable  portion  of  the  respiratory  appara- 
tus remaining  useless  from  birth,  or  becoming  so  afterwards, 
without  any  serious  disease  of  these  organs,  is  a  most  impor- 
tant element  in  the  pathology  of  infancy  and  early  childhood. 

Indeed,  the  dyspnea,  the  hurried  breathing,  and  many  other 
symptoms  which  are  referable  to  obstructed  respiration  may  be, 
in  a  given  case,  not  due  at  all  to  the  beginning  or  progress  of 
an  inflammatory  process,  but  to  the  non-expansion  or  imperfect 
expansion  of  the  lungs. 

Sometimes  mere  feebleness  of  the  respiratory  power  is  re- 
sponsible for  this  failure  of  certain  portions  of  the  lung  to  par- 
ticipate in  the  respiratory  act.  The  pulmonary  cells  are  more 
and  more  emptied  of  air  at  each  expiration,  and  the  weakness 
of  the  chest-walls  is  such  as  to  render  their  subsequent  inflation 
impossible.  Collapse  of  these  lobules  is  the  natural  result. 
Where  but  a  small  portion  of  the  lung  is  thus  incapacitated,  it 
is  often  difficult  to  diagnose  the  trouble  ;  but  the  breathing  is 
more  rapid  than  it  should  be,  and  there  is  no  fever  to  indicate 
that  an  inflammatory  process  is  going  on. 


510  THE  DISEASES  OF  CHILDREN. 

Auscultation  sheds  but  little  light  upon  the  case.  Percussion, 
if  carefully  conducted,  will  afford  more  satisfactory  results,  for 
limited  areas  of  dullness  will  be  apparent.  The  chest  of  a  child 
is  more  sonorous  than  that  of  an  adult  ;  that  is  to  say,  a  more 
resonant  sound  is  elicited  when  percussion  is  resorted  to.  In 
percussing  the  chest  of  a  child,  one  finger  should  be  laid  firmly 
on  the  outer  wall  of  the  chest,  while  one  or  two  fingers,  held 
vertically,  tap  it  slowly  but  lightly.  In  this  way  a  good  reso- 
nant sound  should  be  elicited  anywhere,  although  in  children, 
as  in  adults,  the  apices  and  the  scapular  region  vary  much  in 
resonance  in  conditions  of  perfect  health.  The  stethoscope 
should  always  be  used  in  auscultation  of  infants  and  children. 
The  ear,  however  well  trained,  cannot  be  depended  upon  to 
detect  those  very  limited  areas  of  congestion  or  consolidation 
which  are  so  partial  in  their  distribution  as  to  require  for  their 
detection  that  the  chest  be  gone  over  inch  by  inch,  and  a  care- 
ful comparison  instituted  between  the  two  sides.  It  is  well  to 
remember,  in  making  these  examinations,  that  the  pitch  of  both 
the  inspiratory  and  expiratory  sounds  is  higher  in  children  than 
in  adults.  The  intensify  or  sharpness  of  the  respiratory  mur- 
mur is  what  has  given  rise  to  the  term  "  puerile  respiration." 
This  should  not  be  confounded  with  tubular  or  bronchial  breath- 
ing. In  this  case,  the  inspiratory  sounds  are  shortened,  and 
there  is  a  distinct  interval  of  silence  between  it  and  the  expira- 
tory sound,  which  is  higher  pitched,  louder,  and  more  prolonged. 
This  is  just  the  reverse  of  normal  breathing.  When  there  is 
pleuritic  effusion  in  one  side  of  the  chest,  it  does  not  especially 
alter  the  respiratory  murmur  over  this  side,  except  at  the  apex, 
where  it  often  gives  rise  to  tubular  breathing ;  but  it  is  apt  to 
intensify  the  puerile  character  of  the  respiration  on  the  well 
side  in  a  very  misleading  fashion.  Unless  care  be  exercised,  the 
mistake  is  easily  made  of  regarding  this  enhanced  intensity  of 
sound  to  disease  of  the  well  side,  which  can  only  be  avoided  by 
regarding  the  fixed  or  immobile  condition  of  the  parts  actually 
involved  by  the  pleurisy,  and  by  a  careful  comparison  of  the 
percussion  sounds  of  the  two  sides. 

Another  peculiar  feature  of  disease  involving  the  pulmonary 
tissues  of  infants,  is  the  insidious  manner  with  which  it  creeps 
along,  or  may  creep  along,  sometimes  rapidly,  but  at  other 
times  slowly,  invading  one  portion  of  membrane  after  another, 
until  a  slight  and  localized  inflammation,  scarcely  worthy  of 
special  notice,  suddenly  breaks  out  into  a  widely  extending  and 
serious  affection.  Thus,  a  trifling  nasal  catarrh  may  extend  into 
the  throat  or  into  the  trachea,  and  from  thence  into  the  bron- 
chi;  and  a  case  of  "  snufifles  "  eventuates  in  a  capillary  bron- 
chitis or  a  catarrhal  pneumonia.     The  greatest  care  should  be 


COUGH.  511 

taken,  therefore,  to  watch  the  incipiency  of  all  pulmonary  af- 
fections occurring  in  early  life,  and  so  far  as  possible,  prevent 
their  extension  by  prompt  and  efficient  treatment. 

COUGH, 

Cough  is  a  symptom  which,  to  a  greater  or  less  extent,  accom- 
panies all  affections  of  the  respiratory  apparatus,  but  it  is  also 
a  symptom  of  variable  significance,  and  may  be  present  to  an 
annoying  degree,  independently  of  any  pulmonary  lesion.  The 
stomach  cough  of  children  is  traditional,  and  is  caused  by  irri- 
tation of  some  fibers  of  the  vagus.  Other  varieties  of  cough  of  a 
purely  reflex  character  are  by  no  means  uncommon.  Foreign 
bodies  in  the  ear  will  excite  a  reflex  cough,  which  disappears 
as  soon  as  the  cause  is  removed.  Dry  wax  in  the  ear  will  pro- 
duce the  same  phenomenon.  Umbilical  protrusion  has  been 
reported  as  the  exciting  cause  of  violent  cough  in  a  young 
infant,  which  was  promptly  relieved  by  replacement  and  com- 
pression. There  are  fairly  well  authenticated  cases  where  the 
expulsion  of  tapeworm,  (lumbrici),  lumbricoids  and  other  par- 
asites from  the  alimentary  canal,  has  caused  the  immediate 
arrest  of  a  persistent  and  vexatious  cough.  One  of  the  most 
frequent  and  troublesome  of  these  reflex  coughs  met  with  in 
children  is  the  so-called  **  night  cough,"  which  comes  on  with 
great  regularity  just  before  midnight.  It  is  short,  dry  and  evi- 
dently of  an  irritative  character.  It  is  believed  to  be  of  nasal 
origin,  and  is  due  to  the  presence  of  mucus  in  the  nasal  or 
naso-pharyngeal  chambers.  During  the  day,  when  the  child  is 
up  and  about,  this  mucus,  then  in  a  fluid  state,  escapes  anteri- 
orly ;  but  in  the  recumbent  posture  it  accumulates,  and  becom- 
ing dry,  causes  a  turgescence  of  the  posterior  nasal  erectile 
tissues,  with  the  reflex  phenomenon  of  cough.  Follicular  phar- 
yngitis, acute  and  chronic,  hypertrophy  of  the  tonsils,  so  com- 
mon in  children,  and  an  elongated  uvula,  will  all  give  rise  to 
cough,  which  is  often  paroxysmal,  sometimes  suffocative  and 
always  obstinate.  A  reflex  cough,  strikingly  like  that  ob- 
served in  pertussis,  is  occasionally  caused  by  enlarged  bronchial 
glands.  This  cough  is  noisy  and  paroxysmal,  but  is  not  at- 
tended by  a  whoop.  This  fact,  and  its  non-appearance  in 
epidemic  form,  affecting  only  a  single  individual,  serves  to 
differentiate  it.  The  absence  of  any  definite  and  distinctive 
stages,  and  the  evidence  of  associated  lung  disease,  also  serve  to 
remove  any  doubts  that  may  exist  as  to  its  non-specific  charac- 
ter. Enlarged  bronchial  glands  have  also  a  history  of  wasting 
long  before  the  occurrence  of  the  cough.  The  diagnosis  of 
this  affection  is  aided  greatly  by  following  the  method  of  exam- 


512  THE  DISEASES  OF  CHILDREN. 

ination  laid  down  by  Eustace  Smith.  He  says  :  "  If  the  child 
be  made  to  bend  back  the  head,  so  that  his  face  is  almost  hori- 
zontal, and  the  eyes  look  straight  upwards  at  the  ceiling  above 
him,  a  venous  hum,  varying  in  intensity  according  to  the  size 
and  position  of  the  diseased  glands,  is  heard  with  the  stetho- 
scope, placed  upon  the  upper  bone  of  the  sternum.  As  the 
chin  is  now  slowly  depressed,  the  hum  becomes  less  loudly 
audible,  and  ceases  shortly  before  the  head  reaches  its  ordinary 
position." 

However  we  may  regard  the  philosophy  of  the  production  of 
the  cough  in  a  given  case,  or  however  puzzled  the  pathological 
condition  underlying  it,  our  practical  ends  are  best  subserved 
by  finding  a  remedy  that  will  relieve  it.  In  some  cases,  where 
the  pathological  lesion  is  incurable,  this  will  be  hard  to  accom- 
plish ;  but  oftentimes  a  distressing  cough,  that  in  the  nature  of 
the  case  is  incurable,  may  be  ameliorated  by  finding  a  drug 
which  gives  rise  in  its  pathogenesy  to  a  cough  of  similar 
character. 

To  this  end  the  following  list  of  remedies  and  their  indica- 
tions will  prove  helpful. 

REMEDIES. 

Tight  Cough. — Hepar  sulph.,  phos.,  puis. 

Dry. — Aeon.,  bell.,  con.  mac,  gels.,  hyos.,  nux  vom.,  phos., 
rumex.,  sepia. 

Loose. — Ant.  tart.,  hepar  sulph.,  phos.,  calc.  carb. 

Rattling. — Arg.  nit.,  ant.  carb.,  ipecac,  secale,  sepia. 

Deep. — Arg.  nit.,  hyos.,  phos.,  sticta. 

Racking. — China,  eupat.  perf.,  phos.,  secale,  sepia,  am. 

Hacking. — Puis.,  sepia,  sulph.,  phos. 

Titillating. — Am.  carb.,  cham.,  auphras.,  hyos.,  ign.,  ipec, 
lauxoc,  sepia. 

Paroxysmal. — Bell.,  dros.,  cup.  met.,  gels.,  hyos.,  ipecac,  phos., 
cor.  rub. 

Moist. — Ant.  tart.,  calc.  carb.,  ipec,  kali,  bi.,  sulphur. 

Nervous. — Aeon.,  ambr.,  coff.  c^fud,,  gels.,  hyos.,  ign.,  kali, 
brom.,  platina. 

Spasmodic. — Badiaga,  bell.,  cup.  met.,  dros.,  gels.,  hyos.,  ipe- 
cac, mangan. 

Barking. — Bell.,  bry.,  caust.,  aeon. 

Hoarse. — Hepar  sulph.,  sticta.,  carbo.  veg.,  ign. 

Hollow. — Bry.,  aeon.,  bell.,  nit.  acid,  spongia. 

Wheezing. — Spongia,  aeon.,  bell.,  hyos. 

Aggravation — Morning. — Apis,  baryta  carb.,  bry.,  calc  carb., 
calc.  phos.,  caust.,  china,  coff.  crud.,  crocus,  fer.  met.,  ign.,  ipec, 


5  TMP  TOM  A  TOL  OG  T.  513 

lach.,  nat.  mur.,  nux  vom.,  rhus  tox.,  sang.,  sepia,  silic,  stram., 
thuja,  am.  carb. 

At  night. — Aeon.,  alumina,  ambra,  ant.  tart.,  apis,  arg.  nit., 
ars.  alb.,  bell.,  bry.,  calc.  carb.,  calc.  phos.,  carbo  veg.,  caust., 
cham..,  china,  conium,  dros.,  fer.,  hyos.,  lycop.,  mere,  sol., 
mere,  corn,  nit.  ac,  phos.  ac,  puis.,  silic,  spong.,  sticta.,  thuja, 
verat.  alb. 

On  eating. — Ant.  crud.,  bry.,  calc.  carb.,  calc.  phos.,  china, 
conium,  fer.,  hepar  sulph.,  kali  bi.,  lach.,  mere,  corn,  nux  vom., 
phos.  ac,  puis.,  sepia. 

On  drinking. — Ant.  crud.,  bell.,  calc.  carb.,  china,  fen,  hepar 
sulph.,  ign.,  lach.,  opium,  phos.  ac«,  rhus  tox.,  silic. 

From  excitement. — Nux  vom. 

From  exercise. — Apis,  calc.  carb.,  china,  kali  bi.,  mere  sol., 
nat.  mun,  nit.  ac,  spong.,  stannum. 

On  motion. — Ant.  crud.,  bell.,  bry.,  calc.  carb.,  calc  phos., 
china,  fen,,  gels.,  mere  corn,  nux  vom.,  rhus  tox.,  sang., 
stannum. 

From  cold. — Ant.  crud.,  bell.,  calc  carb.,  calc  phos.,  hepar, 
lach.,  mere  sol.,  phos.  ac,  rhus.,  silic,  sulph. 

From  warmth. — Aeon.,  ant.  crud.,  apis,  bell.,  bry.,  fen,  lach., 
mere,  sol.,  nat.  mun,  opium,  phos.,  puis.,  sulph. 

On  lying  down. — Aeon.,  conium,  dros.,  hyos.,  ign.,  kali,  carb., 
mere,  sol.,  nat.  mun,  nit.  ac,  phos.,  puis.,  silic,  sticta. 

SYMPTOMATOLOGY — SPECIAL    INDICATIONS. 

Aconite. — Especially  in  first  stage ;  cough  hoarse,  dry  and 
short,  or  loud,  hard  and  ringing ;  fever,  dry,  hot  skin  ;  restless- 
ness ;  child  grasps  throat  when  coughing ;  cough  worse  at  night 
and  better  while  lying  quiet. 

Arsenicum. — Fever,  cold,  clammy  perspiration  ;  great  thirst ; 
suffocative  cough  at  night ;  cannot  lie  down  ;  pale,  waxy  skin, 
with  great  prostration. 

Belladonna. — Face  red,  head  congested  ;  cough  is  short,  dry 
and  violent,  or  spasmodic,  hollow  or  barking ;  short,  anxious, 
hurried  breathing. 

Caiisticiim. — Cough  dry,  hollow  and  violent ;  worse  in  morn- 
ings and  evenings,  but  better  when  warm  in  bed  and  from 
swallow  of  cold  water ;  short,  hurried,  panting  respiration,  with 
involuntary  discharge  of  urine  and  feces. 

Chamomilla. — Child  is  peevish,  fretful,  variable  mood  ;  severe 
dry  cough  during  sleep  without  awakening;  paroxysms  of  suf- 
focative cough  at  night  ;  especially  useful  during  dentition. 

China. — Hoarse,  tickling,  spasmodic  cough,  worse  at  night, 
after  eating,  laughing  or  cold  ;  prostration,  without  thirst. 
D.  C— 33 


514  THE  DISEASES  OF  CHILDREN. 

Hepar  sidph. — Cough  deep,  rough,  barking,  or  hoarse  and 
ratthng  ;  cough  excited  by  cold,  uncovering  any  portion  of 
body,  eating  or  drinking  anything  cold,  and  crying  ;  cough 
worse  in  morning  and  better  from  warmth, 

Gelsemium. — Paroxysms  of  hoarse,  spasmodic  cough  ;  child  is 
dull,  languid  and  apathetic  ;  excessively  nervous  ;  loss  of  appe- 
tite. 

Ipecac. — Vomiting  ;  long-lasting  retching  ;  cough  causes  vom- 
iting; paroxysms  of  long-lasting,  violent  cough,  until  child  loses 
its  breath  and  gets  blue  in  face  ;  convulsions  and  spasms  from 
cough. 

Merc.  sol. — Alternate  heat  and  chilliness ;  great  thirst  for 
cold  water ;  cough  short,  dry  and  ringing ;  worse  at  night  and 
from  drinking  cold  water. 

Nux  vom. — Fever,  thirst,  alternate  diarrhea  and  constipa- 
tion ;  dry,  short,  violent  cough,  worse  at  night  ;  cough  worse 
after  eating,  drinking,  cold,  and  lying  on  the  back ;  involuntary 
urination  while  coughing ;  especially  useful  after  patent  medi- 
cines and  cough  mixtures. 

Phosphorus.  —  Emaciation,  with  weakness  and  prostration  ; 
cough  tight,  tickling  and  dry  ;  loose,  hollow  and  rattling  ;  worse 
at  night,  from  eating,  laughing,  motion  and  cold  ;  better  from 
rest  and  quiet. 

Pulsatilla. — Inclination  to  stretch,  yawn  and  throw  off  the 
clothes  ;  chilliness,  without  thirst ;  cough  dry  and  tight  at  night  ; 
loose  during  day  ;  worse  in  evening  and  on  lying  down  ;  better 
on  sitting  up. 

Sulphur. — Child  jumps,  starts  and  screams ;  head  hot  and 
body  cold  ;  cough  short,  dry  and  violent ;  worse  evenings  and 
when  lying  down  ;  hoarseness  with  hurried  respiration. 

Tartar  Emetic. — Child  wants  to  be  carried,  very  restless  and 
cries  when  touched  ;  cough  short,  shrill,  moist  and  rattling ; 
cough  causes  suffocation,  compelling  patient  to  sit  up  ;  cough 
worse  when  lying  down  ;  is  followed  by  gaping,  dozing  or  crying. 

Sambucus.  —  Rough,  wheezing,  suffocative  cough,  waking 
child  about  midnight  ;  cough  causes  child  to  sit  up,  wheeze  and 
gasp  for  breath,  turn  blue  in  the  face  ;  cough  worse  at  night, 
and  while  at  rest,  but  better  while  moving  about ;  follows  well 
after  opium. 


CHAPTER  11. 

CORYZA  (nasal  CATARRH). 

The  mucous  membrane  of  the  nares  is  exceedingly  suscep- 
tible to  catarrhal  inflammation,  and  coryza  is  one  of  the  most 
frequent  of  infantile  maladies.  In  its  most  frequent  form  it  is 
more  a  source  of  discomfort  than  danger ;  but  it  must  not  be 
regarded  as  a  trifling  disorder,  for  oftentimes  a  simple  coryza 
paves  the  way  for  a  more  extended  and  serious  disorder.  It 
seems  to  be  a  well-established  fact  that  diphtheria,  laryngitis, 
pneumonitis,  bronchitis  and  indeed  all  of  the  affections  of  the 
throat  and  lungs  are  most  common  in  those  who  are  the  previ- 
ous subjects  of  catarrh. 

This  statement  is  equally  true  of  tuberculosis.  Any  impedi- 
ment to  the  free  entrance  of  air  to  the  lungs ;  anything  which 
embarrasses  the  respiratory  function  to  any  appreciable  degree, 
is  apt  to  lead  to  congestion,  infarctions,  and  as  a  secondary 
effect,  to  glandular  changes  of  more  or  less  serious  moment. 
We  have  already,  under  the  head  of  General  Considerations, 
spoken  of  the  facility  with  which  all  inflammations  of  the 
mucous  membrane  lining  the  respiratory  tract,  spread  and 
extend  themselves;  and  a  slight  and  inconsequential  catarrh 
may  terminate  in  a  fatal  laryngitis  or  a  serious  affection  of  pul- 
monary lining,  or  parenchyma.  Some  children  seem  to  be 
much  more  subject  to  catarrhs  than  others.  There  are  babies 
that  "snuffle"  from  the  first  hour  of  their  extra-uterine  exist- 
ence ;  while  others,  apparently  no  better  cared  for,  seem  to  be 
almost  exempt  from  colds  and  their  consequences.  Undoubt- 
edly constitutional  dyscrasia  has  much  to  do  with  this,  for  as  a 
rule,  children  that  are  "  always  taking  cold  "  are  of  a  scrofulous 
or  strumous  habit.  It  must  be  admitted,  however,  that  per- 
fectly healthy  children  in  all  other  respects,  once  the  vitality  is 
lowered  by  one  of  the  eruptive  fevers,  or  by  an  attack  of  indi- 
gestion, take  cold  very  readily,  and  one  cold  is  very  prone  to 
be  followed  by  another,  and  another.  During  the  period  of 
dentition  this  is  generally  very  apparent,  for  the  teething  pro- 
cess is  exceedingly  apt  to  be  complicated  by  colds  taken  in 
endless  repetition.  Slight  variations  of  temperature  now  in- 
duce catarrhal  seizures;  or  even,  independently  of  any  such 
exciting   cause,  the  mere   approach  of   a  tooth    towards   the 

(515) 


Si 6  THE  DISEASES  OF  CHILDREN. 

surface  of  the  gum,  often  gives  rise  to  its  symptoms,  which  sub- 
side when  the  source  of  irritation  ceases.  As  pointed  out  by 
West,  such  attacks  often  alternate  with  attacks  of  diarrhea,  or 
the  two  co-exist ;  the  symptoms  of  disturbance  of  the  intestinal 
mucous  membrane  predominating  at  one  time,  those  of  disturb- 
ance of  the  respiratory  membrane  at  another. 

A  large  proportion  of  the  ailments  of  infancy  is  the  direct 
tesult  of  the  extreme  susceptibility  of  these  two  great  mucous 
surfaces,  and  just  as  the  flux  of  to-day  may  to-morrow  take  on 
symptoms  of  acute  dysentery,  so  the  catarrh  of  to-day  may  to- 
morrow have  put  on  the  grave  features  of  acute  bronchitis. 

In  the  first  stage  of  coryza  the  mucous  membrane  of  the 
nasal  passages  is  unusually  dry,  but  this  is  quickly  succeeded  by 
a  discharge,  more  or  less  copious,  of  glairy  thin  mucus,  which 
after  a  time  becomes  altered  in  character;  it  is  thicker,  ichorous 
and  puriform.  In  some  cases,  it  becomes  dry  and  forms  thick 
crusts  about  the  nostrils,  which  almost  occlude  the  nares  and 
render  breathing  through  the  nose  an  impossibility.  Breathing 
by  the  mouth  renders  the  tongue  and  throat  dry  and  parched. 
Whenever  breathing  through  the  nose  is  seriously  interfered 
with,  a  child  at  the  breast  is  unable  to  suck,  and  as  soon  as  it 
has  seized  the  nipple  it  is  compelled  to  let  go,  to  avoid  impend- 
ing suffocation. 

In  this  way  the  child  is  not  only  harassed  by  obstructed 
respiration,  but  in  neglected  or  persistent  cases,  is  worn  out  or 
exhausted  by  lack  of  nourishment.  Such  cases  are  extreme 
and  exceptional,  but  they  do  occur,  and  in  weaklings  such  a 
result  should  not  be  forgotton  as  among  the  possibilities.  The 
cause  of  coryza  is  generally  "  taking  cold,"  but  other  causes  are 
well  known  to  produce  the  same  results,  such  as  the  inhalation 
of  irritating  vapors,  steam,  hot  air  and  dust.  A  foreign  body 
in  the  nose,  such  as  a  bean  or  a  button,  may  also,  by  its  pres- 
ence, set  up  a  most  offensive  and  purulent  discharge,  baffling 
all  the  usual  means  of  relief,  until  the  foreign  body  is  removed. 

Coryza,  as  a  complication  or  as  a  secondary  complaint,  is  fre- 
quently met  with  in  whooping  cough,  measles,  scarlet  fever, 
diphtheria  and  secondary  syphilis. 

Syphilitic  coryza  is  often  extremely  intractable,  and  will  sel- 
dom yield  until  the  constitutional  disease  has  been  brought 
under  subjection.  A  sharp  coryza,  it  should  be  remembered,  is 
very  often  the  avant  courier  of  measles,  and  rarely,  although 
occasionally,  is  of  diphtheritic  origin,  and  may  be  so  when  there 
is  no  visible  lesion  in  the  pharynx  or  elsewhere.  There  is 
usually  some  slight  febrile  movement  associated  with  acute 
coryza,  and  the  infant  or  child  is  restless  and  fretful.  In  nursing 
babes  the  inability  to  suckle  adds  the  pangs  of  hunger  to  the 


CORTZA   {NASAL   CATARRH).  517 

other  sources  of  discomfort,  and  in  their  frantic  efforts  to  ap- 
pease their  appetites,  the  catching  of  the  breath  through  the 
mouth  often  resembles  an  attack  of  laryngismus  stridulous,  and 
may  be  mistaken  for  acute  laryngitis.  In  older  children  this, 
of  course,  does  not  occur,  but  even  they  often  experience  great 
difficulty  in  eating  and  drinking. 

Treatment. — Whenever  there  is  ground  for  suspicion — judg- 
ing from  the  age  of  the  child,  or  the  character  of  the  discharge 
— that  the  coryza  may  be  due  to  mechanical  obstruction  other 
than  inflammation  and  swelling,  an  examination  of  the  anterior 
nasal  chambers  should  be  made  by  means  of  a  small  rubber  ear- 
speculum  or  nasal  dilator,  into  which  a  beam  of  strong  light  should 
be  reflected.  Such  an  examination  may  be  rendered  quite 
painless  by  inserting  into  the  nostril  a  pledget  of  absorbent 
cotton,  wet  in  a  four-per-cent.  solution  of  cocain.  This  should 
be  left  in  situ  for  from  five  to  seven  minutes  before  the  exami- 
nation is  begun.  It  will  not  do  to  apply  the  cocain  by  means 
of  an  atomizer,  because  it  cannot  be  sufficiently  localized  in  its 
anesthetic  effect,  and  for  the  added  reason  that  a  toxic  amount 
of  it  is  liable  to  be  thrown  far  enough  back  to  be  swallowed. 
If  foreign  bodies  or  neoplasms  are  discovered,  they  should,  of 
course,  be  removed. 

For  simple  catarrh,  especially  in  young  infants,  little  treat- 
ment is  usually  necessary.  The  nares  should  be  carefully 
cleansed  with  warm  water  as  often  as  they  become  obstructed, 
and  a  little  goose  grease,  olive  oil,  or  cosmoline  should  be 
smeared  on  the  outside  of  the  nose  and  lips,  and  inserted  within 
the  nares  by  means  of  a  small  pledget  of  cotton.  All  powders 
of  an  astringent  nature,  such  as  tannin,  alum,  nitrate  of  silver, 
sulphate  of  zinc,  should  be  religiously  abstained  from  ;  and  the 
same  should  be  said  of  all  astringent  washes  or  sprays.  They 
are  unnecessary,  and  do  positive  harm  by  irritating  and  congest- 
ing the  already  inflamed  mucous  membrane,  and  only  make 
matters  worse  instead  of  better.  Infants  at  the  breast,  and 
who  are  temporarily  incapacitated  from  nursing,  should  be  fed 
with  a  spoon  until  the  stenosis  is  relieved.  Those  who  are  sub- 
ject to  frequent  attacks  of  coryza  from  taking  cold,  should  be 
made  to  wear  constantly  a  light  flannel  cap,  as  suggested  by 
Dr.  Charles  D.  Meigs. 

Children  who  are  old  enough,  can  be  readily  cured  of  either 
acute  or  chronic  nasal  catarrh,  if  uncomplicated,  by  the  persist- 
ent use  of  a  weak  solution  of  sea-salt. 

It  is  over  twenty  years  since  we  read  in  a  medical  journal  the 
experience  of  a  French  physician,  whose  name  we  have  now 
forgotten,  who  noticed  the  beneficial  effects  to  his  patients  suf- 
fering from  catarrh,  from  visiting  the  seashore  and  bathing  in 


518  rHE  DISEASES  OF  CHILDREN. 

salt  water.  Taking  the  hint  from  numerous  cures  effected  in 
this  accidental  way,  he  began  using  the  sea  water,  which  he  had 
brought  to  him  for  the  purpose  at  his  home  in  the  interior,  and 
with  a  success  that  eclipsed  all  of  his  former  efforts.  Since 
that  time,  we  have  ourselves  used  a  solution  of  sea-salt  in  our 
own  practice,  both  with  adults  and  with  children  of  suitable 
age,  and  the  treatment  has  been  uniformly  successful  when 
faithfully  carried  out.  It  should  always  be  used  warm  and  the 
solution  should  be  only  strong  enough  to  faintly  taste  of  the 
salt.  The  treatment  should  be  used  several  times  daily,  and 
should  be  continued  until  a  cure  is  effected. 

It  may  be  used  as  a  spray  with  an  ordinary  atomizer,  after 
having  cleansed  the  nostrils  as  far  as  possible  with  water  as 
warm  as  can  be  comfortably  borne.  It  will  not  do  to  use  a 
douche  with  this  or  any  other  medicinal  liquid,  for  the  turbi- 
nated surface  is  too  sensitive,  and  inflammation  is  liable  to  be 
excited,  which  will  extend  up  the  eustachian  tube  and  involve 
the  middle  ear. 

Hydrastis  is  a  remedy  of  great  value  in  coryza,  and  may  be 
used  in  the  manner  spoken  of  above.  The  aqueous  fluid  ex- 
tract (colorless)  should  be  used  for  this  purpose,  one-half  or 
two-thirds  diluted  with  warm  water. 

The  remedies  which  will  be  found  most  useful  for  internal  ad- 
ministration in  coryza,  and  which  will  often  be  found  sufficient 
without  resorting  to  local  applications,  are  allium  cepa,  arseni- 
cutn  alb.,  nux  vomica,  naphthalin  ;  sambucus,  sulphur  and  tartar 
emetic. 

Special  indications  for  the  employment  of  each  of  these 
drugs  is  not  deemed  necessary.  Their  relative  value  and  appro- 
priateness in  simple  coryza  will  be  found  usually  in  about  the 
order  given  above. 


CHAPTER  III. 

EPISTAXIS. 

Nosebleed  is  of  very  common  occurrence  in  childhood,  and 
arises  from  a  multiplicity  of  causes.  Indeed,  the  conditions 
under  which  it  occurs  are  so  various  that  it  is  impossible  to 
enumerate  them  all.  Some  children  suffer  again  and  again, 
even  when  not  otherwise  out  of  sorts ;  and  without  any  ten- 
dency to  bleeding  elsewhere.  Sometimes,  however,  it  serves  to 
usher  in  some  acute  disorder,  such  as  one  of  the  exanthemata, 
pertussis  or  acute  pneumonia.  It  is  said  that,  with  the  single 
exception  of  the  horse,  man  alone  among  animals  is  subject  to 
this  form  of  hemorrhage.  In  horses  it  is  exceptional,  and  only 
occurs  under  the  most  violent  exercise. 

In  childhood  it  occurs  so  frequently  that  there  probably  are 
few  persons  who  have  not  at  some  period  experienced  it.  At 
one  time,  and  for  a  very  considerable  period  in  medical  history, 
artificial  blood-letting  was  advocated  and  supported  by  the 
statement  that  spontaneous  bleeding  from  the  nose  was  na- 
ture's safeguard  against  plethora  ;  that  it  not  only  produced  no 
appreciable  harm,  but,  on  the  contrary,  seemed  salutary  in  its 
ei^ects.  Rhinoscopic  examination  of  the  nares  of  children, 
shortly  after  a  hemorrhage,  shows  that  in  at  least  seventy-five 
per  cent,  of  the  cases,  the  bleeding  takes  place  from  certain 
fixed  points  or  areas,  which  have  been  designated  the  "  hem- 
orrhagic points,"  or  *'  points  of  predilection,"  Apparently  these 
are  points  of  least  resistance.  Blowing  or  picking  the  nose, 
vomiting,  coughing,  sneezing,  are  all  liable  to  produce  a  sudden 
engorgement  of  the  nasal  mucous  membrane,  capillary  rupture, 
and  epistaxis.  Nosebleed  is  rarely  observed  in  the  new-born 
or  suckling,  but  becomes  more  common  as  the  child  advances 
toward  puberty.  Boys  are  said  to  be  much  more  subject  to 
epistaxis  than  girls,  but  this  is  probably  due  to  their  more 
boisterous  play,  and  the  more  vigorous  character  of  their 
exercise. 

The  prognosis  in  epistaxis  is  always  good.  Barthez,  Rilliet, 
and  Valliers,  who  have  made  a  critical  examination  of  a  great 
number  of  recorded  cases,  have  failed  to  find  a  single  one  of 
primary  epistaxis  in  children  that  has  proved  fatal.  In  most  cases 

(519) 


520  THE  DISEASES  OF  CHILDREN. 

of  this  kind  no  treatment  is  necessary.  The  hemorrhage  ceases 
spontaneously  after  a  time  in  most  cases  by  coagulation.  If  from 
any  cause  the  density  of  the  blood  is  diminished,  and  coagulation 
takes  place  slowly,  a  dangerous  hemorrhage,  attended  by  pros- 
tration, faintness,  delirium,  and  cardiac  weakness,  may  result  in 
consequence.  In  such  cases  active  measures,  even  to  plugging 
the  nostrils,  if  other  means  fail,  must  be  resorted  to.  Rest  in 
the  sitting  posture  is  of  primary  importance,  with  the  head  in- 
clined slightly  forward,  as  in  writing.  This  position  of  the  head 
places  the  floor  of  the  nostrils  in  a  horizontal  plane,  and  pre- 
vents the  flow  of  blood  into  the  pharynx.  The  mind  of  the 
patient  should  be  quieted,  and  all  fear  and  excitement  dispelled. 
The  nostrils  should  be  compressed,  and  all  attempts  to  expel 
the  clots  prohibited.  Ice  water  should  be  applied  to  the  fore- 
head and  nape  of  the  neck  by  means  of  compresses.  Sometimes 
hot  applications  will  answer  better  than  cold.  A  piece  of  ice 
inserted  into  the  bleeding  nostril  will  often  prove  effectual. 
Galen's  method  of  arresting  nasal  hemorrhage  was  to  apply  a 
large  cupping  glass  to  the  hypochondria.  The  expedient  is 
time-honored  of  making  firm  pressure  upon  the  nostril  or  the 
septum  with  the  finger  of  one  hand,  simultaneously  elevating 
the  arm  of  the  affected  side  above  the  head. 

The  most  effectual  measure,  however,  in  serious  cases  is  to  use 
some  one  of  the  well-known  styptics,  one  of  the  best  of  which 
is  a  solution  of  the  perchloride  of  iron. 

The  nose  should  first  be  cleansed  of  blood  by  injection  of 
water,  after  which  the  perchloride  should  be  sprayed  into  the 
nostril.  The  strength  of  the  solution  should  be  3ii  to  oii  of 
water.  A  tampon  of  cotton  or  charpie  dipped  in  this  same  so- 
lution may  be  used  in  lieu  of  the  spray. 

A  two  to  five  per  cent,  solution  of  cocain  sprayed  into  the 
nose  or  applied  by  means  of  small  pledgets  of  cotton  introduced 
gently  into  the  nostril,  is  said  to  have  checked  some  cases  of 
most  obstinate  hemorrhage. 

Therapeutics. — There  are  numerous  remedies  that  are  of  re- 
puted value  in  epistaxis  when  administered  internally.  Of  these, 
the  leading  ones  are  ^^c'«//^,  arnica^  hamamelis,  belladonna,  china ^ 
erigeron,  and  ledum. 

The  latter  was  the  favorite  of  the  late  Dr.  George  E.  Ship- 
man.  Dr.  Gilchrist  says :  "  In  cases  of  epistaxis  of  almost  any 
kind,  erigeron  has  never  failed  me.  I  use  the  strong  tincture, 
and  administer  it  by  olfaction.  One  or  two  smells  of  it  has  al- 
ways sufficed." 

In  cases  where  the  epistaxis  is  due  to  anemia  or  chlorosis, 
china  or  ferrum  met.  should  be  given,  or  perhaps  still  better, 
ferrated  cod-liver  oil.     Dr.  S,  Hohn  says  that  he  has  found  the 


EPISTAXIS.  521 

fluid  extract  of  hydrastis  canadensis  "  a  sovereign  remedy  in 
these  cases  ;  "  he  has  had  occasion  to  use  it  in  a  large  number  of 
cases  of  nosebleed  in  the  German  Poliklinik  (New  York),  and 
has  found  it  efficacious  in  preventing  a  recurrence  in  a  large 
majority  of  cases.  It  is  administered  internally,  in  ten-drop 
doses  in  water,  every  two  or  three  hours.  '*  The  hydrastis,"  he 
says,  "  is  prescribed,  be  it  understood,  as  a  preventive  for  the 
patient  who,  at  the  time  of  his  visit,  is  not  bleeding  from  the 
nose,  but  who  has  a  history  of  repeated  bleedings." 

A  five-per-cent.  solution  of  the  fluid  extract  of  hydrastis  in 
water  may  be  used  as  a  spray  for  the  nose ;  it  may  also  be  used 
with  liquid  vaseliii,  albolin,  or  kindred  preparations,  as  a  spray 
or  brushed  into  the  nose.  The  drug  seems  to  "  tone  "  the  mucous 
membrane ;  and  by  reason  of  its  containing  a  bitter  principle  it 
has,  when  taken  internally,  a  beneficial  effect  on  the  stomach, 
as  is  attested  by  the  improved  appetite  following  its  use ;  its 
only  drawback  is,  that  it  has  a  tendency  to  cause  constipation, 
but  this  may  be  combated  by  mild  salines. 

Dr.  Hohn  proceeds  to  give  his  own  method  of  arresting 
nasal  hemorrhage  as  follows  :  "  It  has  seemed  to  the  writer  that 
the  simple  rules  for  the  stoppage  of  capillary  hemorrhage  are 
applicable  to  these  cases  ;  the  object  is,  as  in  any  hemorrhage, 
to  secure  coagulation  at  the  point  of  bleeding,  and  to  keep  the 
clot  in  place. 

"  The  first  rule,  therefore,  is  to  place  the  patient,  and  more 
especially  the  bleeding  part,  at  rest ;  nervousness  or  fright  should 
be  quieted  with  assurances  that  there  is  absolutely  no  danger  ; 
the  patient  should  sit  upright  in  a  chair,  the  head  thrown 
slightly  backward  ;  all  bands  about  the  neck  should  be  loosened, 
in  order  that  the  circulation  may  be  unimpeded  ;  the  patient 
should  then  open  the  mouth  as  widely  as  possible,  and  should 
breathe  through  the  mouth  only ;  breathing  through  the  nose 
should  be  entirely  suspended  until  bleeding  ceases,  and  should 
be  superseded  by  oral  breathing ;  blowing  the  nose,  hawking, 
and  spitting  must  be  strictly  interdicted ;  we  all  know  how 
prone  patients  suffering  from  nosebleed  are  to  do  these  things. 
In  following  the  instructions  thus  far  given,  the  interior  of 
the  nose  is  placed  at  rest,  and  the  first  indication  is  fulfilled ; 
whereas,  if  the  patient  snuff  up  cold  water,  wipe  or  blow  the 
nose,  he  displaces  clots  and  favors  the  continuance  of  the 
hemorrhage. 

"  The  second  rule  is  to  tell  the  patient,  his  mouth  being  kept 
wide  open,  to  breathe  more  deeply  and  more  rapidly  than  he 
normally  does  ;  the  respiration  may  be  increased  to  thirty  per 
minute ;  the  immediate  effect  of  this  increased  oxygen  supply 
is  to  increase  the  force  and  frcuency  of  the  heart's  action,  and 


522  THE  DISEASES  OF  CHILDREN. 

presumably  to  increase  the  amount  of  blood  in  the  pulmonic 
circulation  at  the  expense  of  the  cerebral ;  whether  it  be  due  to 
the  more  thorough  equalization  of  the  blood  supply  to  the 
body  and  head,  or  to  the  increased  muscular  action  incident  to 
the  increased  respiratory  effort,  it  has  seemed  to  the  writer  that 
the  nasal  mucous  membrane  is  depleted  to  some  extent  by  this 
procedure. 

"  The  use  of  opium  and  digitalis  in  hemoptysis  is  to  a  certain 
extent  attended  by  the  same  result  here  obtained,  viz.,  a  more 
powerful  contraction  of  the  heart-muscles. 

"As  soon  as  the  patient  tires  of  the  rapid  breathing — which 
he  does  very  soon,  perhaps  after  thirty  respirations — he  may 
breathe  normally  for  a  few  moments,  when,  if  the  bleeding  ha? 
not  ceased,  he  is  told  to  breathe  rapidly  again  ;  the  mouth  is 
to  be  kept  open  constantly,  and  any  blood  flowing  into  the 
pharynx  to  be  swallowed. 

"  The  fact  that  blood  is  withdrawn  from  the  brain  by  this 
procedure  is  attested,  in  the  opinion  of  the  writer,  by  the  dizzi- 
ness which  most  patients  experience  when  they  resort  to  it, 
and  by  the  pallor  which  the  face  assumes  ;  the  same  symptoms 
have  been  noted  by  every  physician  during  prolonged  auscul- 
tatory examinations  of  the  chest  ;  some  patients  are  apt  to  faint 
during  such  examinations  ;  it  seems  to  the  writer  that  a  tempo- 
rary anemia  of  the  brain  is  the  cause  of  these  phenomena. 

"  The  final  rule  is,  to  tell  the  patient  to  enunciate  the  broad 
vowel  'A'  with  each  expiration  ;  the  soft  palate  is  thus  brought 
in  contact  with  the  posterior  wall  of  the  pharynx  during  each 
expiration,  the  posterior  nares  are  separated  from  the  pharynx, 
and  the  blood  is  prevented  from  flowing  into  the  esophagus 
during  the  expiratory  periods. 

"  The  three  principal  factors  in  this  simple  method  of  arrest- 
ing nosebleed  are,  first :  to  place  the  nose  at  rest  by  suspending 
breathing  through  it ;  second  :  rapid  and  profound  respiration, 
acting  as  a  respiratory  and  cardiac  stimulant,  more  equally  dis- 
tributing the  blood  throughout  the  systemic  and  pulmonary 
circulation  by  abstracting  it  from  the  head  ;  and  third :  the 
occlusion  of  the  posterior  nares  during  the  entire  expiratory 
period  by  the  intonation  of  the  broad  vowel  'A'  during  expira- 
tion. 

"  This  method  is  so  easily  applicable  that  after  every  opera- 
tion in  the  nose  attended  by  bleeding  the  writer  makes 
use  of  it ;  it  is  so  much  cleaner  and  simpler,  after  the  snaring 
of  a  vascular  polyp  or  the  removal  of  an  exostosis,  to  make  use 
of  this  procedure  than  to  apply  astringents  that  interfere  with 
the  field  of  operation,  that  it  is  invariably  tried  by  the  writer 
before  any  other  means  are  applied.   Of  course  it  may,  in  some 


EPISTAXIS.  523 

cases  of  severe  bleeding  from  a  larger  vessel,  fail ;  in  these  I 
would  then  try  first  the  insufflation  of  tannin  ;  and  if  this  fail 
the  tamponing  of  the  nostril  with  long,  narrow  strips  of  iodo- 
form gauze,  dipped  in  the  glycerite  of  tannin,  with  the  ends 
hanging  out  of  the  nostril.  It  is  needless  to  dwell  on  the  ad- 
vantages of  a  method  of  arresting  nasal  hemorrhage  in  which 
no  drugs  or  instruments  of  any  kind  are  necessary." 


CHAPTER  IV. 

TONSILITIS   (inflammation   OF   THE   TONSILS). 

This  affection  is  sometimes  called  quinsy  or  amygdalitis. 
The  tonsils  are  two  almond-shaped  glandular  bodies  situated 
in  the  mucous  membrane  at  the  sides  of  the  base  of  the  tongue, 
just  between  the  two  pillars  of  the  fauces.  When  the  mouth 
is  opened  widely  they  are  thrown  forward,  and  made  more 
prominent  by  the  tension  of  the  posterior  faucial  pillars.  They 
are  of  variable  size,  being  sometimes  nearly  absent,  and  again 
are  so  large  as  to  force  the  pillars  of  the  fauces  out  of  their 
usual  position  and  make  a  mass  of  considerable  size  in  front  of 
the  pharynx.  In  bilateral  quinsy,  they  are  sometimes  so  swol- 
len as  nearly  to  touch  the  uvula. 

According  to  Lennox  Browne,  the  tonsils,  when  normal,  should 
not  protrude  beyond  the  plane  of  the  anterior  pillars.  This 
variability  in  size  may  be  considerable  without  occasioning  any 
morbid  symptoms,  or  producing  any  discomfort  to  the  indi- 
vidual. The  tonsils  belong  to  the  class  of  lymphatic  glands. 
They  are  composed  largely  of  connective  tissue,  in  which  are 
imbedded  numerous  follicles,  compound  in  character,  whose 
ducts  open  into  one  another,  and  terminate  in  ten  or  a  dozen 
orifices  of  variable  form.  These  orifices  are  plainly  visible  on 
the  surface  of  the  tonsil,  and  mark  the  entrances  to  the  crypts 
or  lacunae.  The  arterial  supply  of  the  tonsil  is  abundant,  and 
is  in  proportion  to  the  size  of  the  gland.  It  comes  from  the 
inferior  pharyngeal  and  the  two  palatine  arteries,  and  these 
branches  are  often  so  large  as,  when  cut,  to  give  rise  to  serious 
and  even  alarming  hemorrhage. 

The  function  of  the  tonsils  has  been  a  matter  of  much  dis- 
pute, and  is  even  now  involved  in  uncertainty.  The  latest 
researches,  however,  indicate  that  their  function  is  two-fold. 

In  the  first  place,  the  crypts  or  lacunae,  are  reservoirs  of  a 
clear,  viscid  fluid,  resembling  in  character  that  which  is  secreted 
by  the  small  buccal  glands.  It  is  destined  to  lubricate  the  ali- 
mentary bolus  and  to  facilitate  its  passage  through  the  isthmus 
of  the  fauces  and  the  esophagus. 

In  the  second  place,  they  contain  numerous  closed  or  duct- 
less follicles,  which  are  situated  in  the  deeper  layers  of  the 
tonsil ;  and  in  this  respect  they  resemble  other  ductless  or 
(524) 


TONSILITIS.  5i>5 

blood  glands,  such  as  the  lymphatic  ganglia,  the  spleen,  the 
thymus,  etc.,  and,  like  them,  they  modify  notably  some  of  the 
constituents  of  the  blood,  and  aid  in  the  formation  of  the  white 
corpuscles.  The  tonsils  are,  however,  from  a  functional  or 
physiological  point  of  view,  merely  adjuncts  of  other  organs, 
and  bear  but  a  minor  part  in  the  elaboration  of  the  blood,  and 
hence  their  extirpation  does  not  lead  to  any  serious  disturbance 
of  nutrition  or  materially  affect  the  general  health.  It  is  in  the 
bottom  of  the  lacunae,  above  mentioned,  that  those  cheesy 
masses  are  formed  which  are  so  offensive  in  certain  inflamma- 
tions of  the  gland.  These  cheesy  masses  sometimes  become 
hard  and  transformed  into  calculi.  The  tonsils  are  very  prone 
to  both  acute  and  chronic  inflammation.  In  the  latter  case,  the 
inflammation  nearly,  but  not  quite  always,  results  in  more  or 
less  hypertrophy  or  enlargement  of  the  gland. 

In  acute  tonsilitis,  occurring  in  early  childhood,  there  does 
not  seem  to  be  the  same  tendency  to  suppuration  that  obtains 
later  in  life.  (.1  do  not  think  I  have  ever  seen  a  case  of  suppu- 
rative tonsilitis  in  a  child  under  the  age  of  pubertyO 

In  childhood  and  youth  tonsilar  inflammation  is  very  com- 
mon,  but  not  so  common  as  in  early  adult  life.  It  is  rare  in 
infancy,  although  enlargement  of  the  tonsils  is  very  frequently 
met  with,  even  in  very  young  infants. 

Temperament  seems  to  have  much  to  do  in  the  production 
of  acute  inflammation  of  the  tonsils.  It  is  most  common 
among  pale  and  lymphatic  girls  and  boys.  Enlargement  or 
hypertrophy  of  the  tonsils  is  very  conducive  to  inflammation 
of  these  organs,  and  one  attack  renders  the  patient  more  liable 
to  a  recurrence.  Such  persons  are  very  liable  to  sore  throat 
from  the  slightest  disturbance  of  stomach  or  bowels,  or  any  un- 
due exposure  to  cold  or  dampness.  Tonsilitis  is  much  more 
prevalent  in  seasons  of  rapid  changes  of  temperature,  such  as 
are  common  in  our  variable  cHmate  during  the  spring  and 
autumn.  It  is  also  a  well-known  fact  that  tonsilitis  is  more 
prevalent  when  measles,  scarlatina  and  diphtheria  are  also  pre- 
vailing. Among  the  direct  causes  of  tonsilitis,  the  principal 
ones  are  undoubtedly  the  influence  of  cold  and  wet  acting 
locally  on  the  neck  or  feet.  Sitting  in  a  draught  when  warm 
and  perspiring,  getting  the  feet  damp,  neglecting  to  change 
the  clothing  after  getting  it  wet ;  these  are  unquestionably  the 
most  proHfic  causes  of  the  disease. 

Indirectly,  certain  atmospheric  and  local  conditions  probably 
predispose  to  tonsilitis,  and  the  same  may  be  said  of  septic  in- 
fluences, such  as  bad  sewerage  and  the  vitiated  atmosphere  of 
illy-ventilated  homes.  It  is  said  by  Kingston  Fox  that  the  dif- 
ferential diagnosis  from  acute  tonsilitis,  due  to  cold  or  other 


526  THE  DISEASES  OF  CHILDREN. 

simple  causes,  is  made  by  the  fact  that  the  septic  cases  are 
bilateral  in  the  beginning,  while  the  others  are  unilateral,  as  a 
rule.  There  is  so  much  evidence  that  bad  sanitary  influences 
participate  in  the  causation  of  tonsilitis,  that  whenever  a  child 
is  continually  complaining  of  his  throat,  and  the  tonsils  are  the 
seat  of  repeated  attacks  of  inflammation,  it  is  almost  certain 
that  a  careful  inspection  of  the  apartments  will  disclose  the 
cause  in  defective  drainage,  or  other  unsanitary  conditions.  It 
goes  without  saying  that  when  this  is  the  case  the  producing 
cause  must  be  removed  before  the  child  can  be  made  perma- 
nently well,  and  future  attacks  averted. 

Symptoms. — For  convenience  of  description,  tonsilitis  may 
be  divided  into  acute  and  chronic,  the  latter  being  attended 
with  more  or  less  permanent  hypertrophy  of  the  gland. 

In  the  acute  variety,  the  inflammation  often  begins  with  a 
chill,  and  is  always  attended  with  fever,  the  temperature  ranging 
from  ioi°  to  as  high  as  103°  Fahr.  There  is  aching  and  sore- 
ness of  the  muscles  generally,  the  same  as  is  experienced  in 
the  beginning  of  a  severe  catarrh.  The  pulse  is  rapid  and  full, 
and  the  tongue  is  furred  and  red  at  the  edges.  There  is  headache. 
The  tonsils  are  swollen  and  red,  and  there  is  much  pain  expe- 
rienced when  swallowing  is  attempted.  An  inspection  of  the 
throat  reveals  the  fact  that  not  only  are  the  tonsils  involved, 
but  also  the  uvula,  the  pharynx  and  the  pillars  of  the  fauces. 
The  uvula  is  not  usually  swollen  at  the  commencement  of  the 
attack,  but  commonly  becomes  edematous  later  on.  The  pain 
experienced  in  deglutition  increases  as  the  disease  progresses, 
until  the  child  is  afraid  or  unable  to  swallow,  «and  any  attempt 
to  do  so  produces  a  muscular  spasm,  and  a  return  of  the  fluid 
through  the  nose.  The  pain  which  accompanies  deglutition  is 
sharp  in  character,  and  it  shoots  up  into  the  ears  and  side  of 
the  head.  All  movements  of  the  jaws  are  painful.  Sing- 
ing or  buzzing  in  the  ears  is  often  present,  and  adds  another 
uncomfortable  factor  to  the  general  suffering. 

At  the  height  of  the  disease  the  temperature  is  often  as  high 
as  104°  Fahr.  The  skin  is  usually  moist  and  clammy,  and  the 
face  is  anxious,  haggard  and  distressed. 

Fortunately  for  the  patient,  the  pain  and  suffering  are  out  of 
all  proportion  to  the  gravity  of  the  disease,  and  after  a  few  days, 
and  in  mild  cases  in  a  few  hours,  the  distress  is  greatly  amel- 
iorated. In  some  cases,  almost  at  the  beginning,  and  in  others 
after  the  lapse  of  a  day  or  two,  there  is  seen  on  the  tonsils 
scattered  spots  or  flecks  of  exudate  from  the  lacunje,  each  spot 
marking  the  orifice  of  one  of  the  ducts.  These  exudations  are 
grayish  in  color,  and  are  often  mixed  with  a  glairy  mucus, 
which  covers  to  a  greater  or  less  extent  the  surface  of  the  tonsil, 


TONSILITIS.  527 

but  does  not  dip  into  its  recesses  and  become  firmly  adherent; 
like  the  exudative  patch  seen  in  diphtheria.  Indeed,  the  filmy 
exudate  which  occurs  in  tonsilitis  can  be  wiped  off  with  a  camel's- 
hair  brush,  and  does  not  leave  a  raw,  ulcerated,  or  bleeding 
surface  underneath  it.  When  there  is  considerable  swelling 
of  the  tonsils,  the  voice  is  thickened,  and  assumes  a  character- 
istic nasal  intonation.  Besides  the  exudation  on  the  tonsils,  all 
of  the  muciparous  glands  of  the  mouth  take  on  increased  ac- 
tivity, and  viscid,  stringy  mucus  collects  in  the  throat,  which  is 
expectorated  with  difficulty,  and  by  very  young  children  is 
swallowed.  In  cases  where  the  disease  is  distinctly  follicular — 
that  is  to  say,  when  the  exudate  is  scattered  over  the  tonsil, 
marking  the  mouths  of  the  crypts — the  constitutional  symptoms, 
such  as  fever,  chills,  pain  and  general  malaise,  are  greater  than 
in  others  where  the  inflammation  is  more  superficial.  Some 
authors  make  a  distinction  between  these  varieties — the  super- 
ficial or  the  erythematous  ;  and  the  follicular  or  lacunal ;  but 
there  is  in  the  writer's  estimation  little  advantage  in  such  a  dif- 
ferentiation. The  causes  are  precisely  the  same ;  the  general 
symptoms  are  the  same.  The  only  difference,  indeed,  is  that 
in  the  follicular  variety  of  tonsilitis,  the  inflammation  extends 
into  the  lacunae,  and  involves  the  follicles  to  a  greater  extent 
than  does  the  simple  or  erythematous,  and  in  consequence,  the 
fever  is  apt  to  be  higher,  and  the  other  symptoms  somewhat 
aggravated.  It  may  be  said,  however,  that  in  follicular  tonsil- 
itis, the  exudation  is  apt  to  be  more  cheesy  in  character,  and 
to  project  out  from  the  follicular  orifices,  instead  of  forming  a 
slimy  or  creamy  patch  over  a  considerable  tonsilar  area.  There 
is  another  form  of  tonsilitis,  called  the  parenchymatous  or 
suppurative,  which  occasionally,  though  rarely,  affects  children. 
It  is  more  common  after  puberty,  and  especially  after  maturity 
is  reached.  This  is  the  so-called  "  quinsy  "  of  the  laity.  In 
this  variety  of  tonsilitis,  all  of  the  symptoms  just  described  are 
intensified.  The  fever  may,  perhaps,  be  no  higher,  but  the  ton- 
sils are  more  swollen  ;  the  pain  in  swallowing  is  greater,  and 
there  is  often  considerable  dy^^ea  from  occulsion  of  the  throat 
from  the  intensely  enlarged  glands,  which  in  severe  cases  nearly 
touch  each  other  in  the  median  line.  The  inflammation  is  so 
diffused,  and  involves  to  such  an  extent  the  pillars  of  the 
pharynx  and  the  adjacent  connective  tissue,  that  it  is  almost 
impossible  for  the  patient  to  open  the  mouth  for  inspection. 
Quinsy  generally  begins  on  one  side  ;  and  after  a  period  vary- 
ing from  three  to  five  days,  the  opposite  tonsil  becomes  in- 
volved. Where  both  tonsils  are  affected  from  the  beginning, 
there  may  be  great  difficulty  in  breathing,  and  the  general  dis- 
tress be  very  great.     After  the  disease  has  run  a  course  of  from 


528  THE  DISEASES  OF  CHILDREN. 

five  to  seven  days,  a  yellowish  spot  can  sometimes  be  seen  on 
the  reddened  and  glossy  surface  of  the  gland,  showing  where 
the  pus  is  most  superficial.  At  this  point  the  abscess  will  soon 
burst  and  a  quantity  of  pus  be  discharged.  As  soon  as  this 
occurs,  immediate  relief  is  experienced  ;  the  fever  abates,  and 
in  a  few  days  the  whole  trouble  is  over. 

Course  and  Duration. — Tonsilitis  varies  greatly  in  its  course, 
gravity  and  duration.  In  its  simplest  form  it  may  be  so  mild 
as  to  attract  but  little  attention.  A  slight  soreness  of  the 
throat,  lasting  for  twenty-four  or  forty-eight  hours,  with  but 
little  fever  and  no  constitutional  symptoms,  may  constitute 
the  whole  attack.  In  cases  of  average  or  moderate  severity, 
the  duration  of  marked  symptoms  is  from  three  to  five  days. 
When  the  inflammation  of  the  tonsils  goes  on  to  suppuration, 
the  duration  is  longer,  for  although  it  is  unusual  for  both  ton- 
sils to  suppurate  during  the  same  attack,  it  is  quite  common  for 
the  inflammation  to  extend  to  the  opposite  side,  and  in  this  way 
to  prolong  the  disease.  An  attack  of  quinsy  is  rarely  recov- 
ered from  in  less  than  from  ten  days  to  two  weeks. 

Abscess  of  the  tonsils  usually  points  anteriorly  towards  the 
buccal  cavity,  but  in  rare  instances  it  has  been  known  to  evacu- 
ate itself  posteriorly.  While  the  abscess  is  in  process  of  forma- 
tion, the  pains  are  of  a  lancinating  character,  and  are  accom- 
panied by  well-marked  rigors.  In  children  who  have  suffered 
from  tonsilitis  repeatedly,  the  glands  are  usually  permanently 
enlarged. 

Diagnosis. — The  only  trouble  likely  to  be  experienced  in 
properly  diagnosing  tonsilitis  is  in  distinguishing  the  follicular 
variety  from  a  mild  diphtheria.  Sometimes  this  is  extremely 
difficult.  The  exudation,  which  at  first  distinctly  marked  the 
orifices  of  the  lacunae,  sometimes  coalesces,  and  forms  a  consec- 
utive patch  of  membrane  that  closely  resembles  the  diphthe- 
ritic pellicle.  If  seen  early  in  the  attack,  the  diagnosis  is 
simplified,  for  the  exudate  is  then  scattered  and  is  whiter, 
while  the  exudate  is  more  elevated  or  punctated.  It  is  easily 
removed  from  the  surface  by  means  of  a  throat  probang 
or  brush,  while  the  diphtheritic  deposit  is  more  gray,  more 
adherent,  and  tougher,  and,  if  forcibly  removed,  leaves  behind 
a  raw  and  bleeding  surface.  There  is  sometimes  but  little  dif- 
ference in  the  foulness  of  the  odor  that  proceeds  from  the 
mouth  in  the  two  diseases.  While  that  of  diphtheria  is  usually 
more  pungent  and  fetid,  we  have  seen  cases  of  tonsilitis  where 
the  breath  was  equally  foul. 

In  determining  the  precise  nature  of  a  tonsilitis,  we  may 
have  to  wait  until  we  can  observe,  for  a  few  hours  at  least,  the 
course  and  behavior  of  the  exudation.     That  of  diphtheria  is 


CHRONIC  TONSILITIS.  529 

more  rapid  in  its  spread,  and  if  it  be  detached,  is  rapidly  repro- 
duced. Dr.  Lennox  Browne  has  called  attention  to  one  point 
of  differentiation  between  lacunal  tonsilitis  and  diphtheria, 
which  is  of  great  practical  help  in  doubtful  cases,  and  so  far  as 
our  own  experience  goes,  it  is  a  point  well  taken.  He  says : 
"  The  membrane  in  tonsilitis  is  limited  to  the  tonsils  themselves, 
whereas  in  diphtheria  it  is  extremely  rare  not  to  see  patches  at 
the  same  time  on  the  uvula  and  the  soft  palate." 

Prognosis. — Except  in  extremely  rare  cases,  the  prognosis  is 
always  good.  This  statement,  however,  refers  to  the  hazard  to  life 
only.  Children  of  a  debilitated  and  strumous  constitution  are 
much  pulled  down  by  it,  and  the  outlook  into  the  future  is  the 
more  grave,  because  one  attack  is  quite  certain  to  be  followed 
by  others,  and  this  tendency  increases  with  every  fresh  out- 
break. 

Treatment. — The  remedies  which  will  be  found  of  most  value 
in  the  treatment  of  tonsilitis  are  belladonna,  kali  bichromicum, 
tartar  emetic,  and  mercurius.  In  the  milder  form,  and  at  the 
beginning  of  an  attack,  where  there  is  intense  redness,  pain  and 
tenderness,  bell,  will  meet  all  the  requirements  of  the  case. 

Where  the  exudation  is  considerable,  and  the  mouth  is  filled 
with  a  viscid,  glairy,  stringy  mucus,  kali  is  to  be  preferred.  In 
cases  where  the  indications  warrant  it,  the  two  remedies  may 
be  given  in  alternation.  Mercurius  biniodide  is  useful  in  cases 
where  there  is  swelling  of  the  external  cervical  glands,  and  out- 
side tenderness  in  connection  with  the  internal  trouble.  Apis 
inel.  is  indicated  when  the  tonsilitis  is  of  the  superficial,  or 
erythematous  variety,  accompanied  with  puffiness  of  the  uvula, 
which  looks  like  an  inflated  bladder,  or  a  bag  of  jelly.  Hepar 
sulph.  is  of  value  when   suppuration  is  inevitable,  but  delayed. 

The  inhalation  of  steam  is  always  grateful,  and  may  be  medi- 
cated with  apple-vinegar  or  permanganate  of  potash,  if  there  is 
much  fetor  to  the  breath.  Cloths  wrung  out  of  hot  water,  or 
hot  flaxseed  poultices  applied  to  the  outside  of  the  neck,  will 
hasten  suppuration  where  this  cannot  be  avoided,  and  shorten 
the  duration  of  suffering.  As  soon  as  a  point  is  discovered 
where  the  abscess  is  disposed  to  break,  a  sharp-pointed  bistoury 
should  be  used  ;  the  blade,  all  but  its  tip,  having  been  pre- 
viously wrapped  with  adhesive  plaster  in  order  to  limit  the 
depth  of  the  incision. 

CHRONIC  TONSILITIS  (HYPERTROPHY  OF  THE  TONSILS). 

This  form  of  tonsilitis  differs  in  many  material  respects  from 
that  which  we  have  just  considered.     Repeated  attacks  of  acute 
tonsilitis  may,   indeed,  leave  these  glands  hypertrophied,  but 
D.  C— 34 


530  THE  DISEASES  OF  CHILDREN. 

this  is  not  always  the  case ;  the  acute  inflammation  often  hav- 
ing precisely  the  opposite  effect,  and  leaving  them  shrivelled 
and  atrophied. 

Chronic  hypertrophy  is  generally  insidious  in  its  approach 
and  progress,  and  does  not  necessarily  imply  previous  attacks 
of  acute  inflammation.  It  is  sometimes  congenital,  or  shows 
itself  so  soon  after  birth  as  to  leave  little  ground  to  doubt  of 
its  hereditary  origin. 

This  view  of  its  etiology  is  confirmed  by  the  family  history^ 
for  it  will  be  often  found  that  other  members  of  the  family  have 
suffered  in  the  same  manner,  and  very  likely  the  parents  will 
tell  you  that  they  themselves  were  thus  afflicted  in  their  early 
childhood.  Some  observers  have  endeavored  to  trace  a  con- 
nection between  chronic  tonsilitis  and  struma  or  rickets,  but 
such  efforts  have  not  been  substantiated  by  extended  observa- 
tions. Many  cases  will  be  met  with  where  the  tonsils  are 
notably  enlarged,  and  where  there  is  a  total  absence  of  other 
indications  of  ill-health.  In  most  cases  chronic  hypertrophy  is 
of  trifling  import,  or  would  be  so  but  for  the  tendency,  which 
is  well  marked  in  all  cases,  of  predisposing  to  inflammations  of 
these  same  organs  of  an  acute  and  more  serious  character. 

Once  chronic  enlargement  of  the  tonsils  has  been  established, 
every  trifling  disturbance  of  system  or  accidental  exposure  to 
cold,  is  sufficient  to  determine  a  new  and  acute  inflammation, 
not  of  these  glands  alone,  but  of  glands  adjacent,  and  of  the 
mucous  membrane  of  the  pharynx  as  well.  In  infants  thus 
affected,  the  process  of  teething  is  frequently  attended  with 
more  than  the  usual  disturbances,  and  scarlatina  and  diphtheria 
are  both  apt  to  be  complicated,  if  not  encouraged,  by  this  con- 
dition of  chronic  hypertrophy.  The  causes  of  this  affection, 
aside  from  hereditary  influence  already  referred  to,  are  obscure. 
Delicate  children  with  thick  lips,  and  gross,  ill-formed  features, 
suggestive  of  the  strumous  constitution ;  and  children  who  are 
particularly  subject  to  disorders  of  digestion,  are  the  favorite 
victims  of  chronic  tonsilitis;  and  so  are  the  children  of  the  poor 
who  live  in  basements,  and  who  breathe  a  vitiated  atmosphere, 
living  upon  poor  and  insufficient  food,  and  deprived  of  suffi- 
cient sunlight.  Tonsilar  enlargement  may  manifest  itself  at 
any  time  succeeding  birth,  but  is  most  commonly  observed 
between  the  ages  of  two  and  ten  years.  Occasionally  the  child 
reaches  puberty  before  attention  is  called  to  the  disorder,  and 
then  it  is  quite  naturally  associated  with  sexual  development. 
As  regards  sex,  it  is  noticeably  more  frequent  in  boys  than  girls. 
The  duration  of  chronic  enlargement  of  the  tonsils  is  indefinite. 
Some  children  undoubtedly  outgrow  it,  owing  to  a  better  state 
of  the  general  health,  while  the  changes  which  take  place  at 


CHRONIC  TONSILITIS.  531 

puberty  often  exercise  a  salutary  influence,  and  stop  the  in- 
crease, if  they  do  not  effect  a  permanent  resolution.  Indeed, 
in  the  majority  of  cases,  after  puberty  the  affection  ceases  to 
be  a  disease  of  importance,  or  to  cause  any  special  annoyance, 
for  even  if  the  tonsils  are  not  materially  diminished  in  size,  the 
increased  dimensions  of  the  throat  and  fauces  give  more  room, 
and  thus  relieve  any  discomfort  there  may  have  been. 

It  is  stated  by  Bosworth  that  true  hypertrophy  of  the  ton- 
sils never  disappears,  except  by  excision,  and  has  a  far  greater 
tendency  to  increase  than  to  remain  in  statu  quo.  The  extent 
to  which  hypertrophy  may  go  is  very  variable.  In  extreme 
cases  the  tonsils  are  so  much  enlarged  that  they  touch  the 
uvula  on  either  side,  and  when  this  is  the  case  the  breathing 
is  seriously  interfered  with.  Usually  the  enlargement  is  only 
moderate  in  extent,  and  does  not  interfere  seriously  with 
respiration.  It  does,  however,  interfere  with  free  vocaliza- 
tion and  gives  a  nasal  twang  to  the  voice.  Chronic  coryza 
is  frequently  associated  with  chronic  hypertrophy  of  the 
tonsils.  When  this  condition  of  the  tonsils  exists,  the  glands 
are  not  only  enlarged,  but  indurated.  They  have  the  appear- 
ance of  light  red  or  pink  tumors,  and  if  due  to,  and  asso- 
ciated  with,  frequent  attacks  of  acute  inflammation,  their 
surfaces  are  studded  with  depressions,  or  small  excavations, 
rendering  them  uneven  or  somewhat  honeycombed  from  rup- 
tured follicles  or  congested  and  enlarged  lacunae.  In  other 
cases  the  surface  is  smooth  and  glistening.  When  pressed 
upon  by  the  finger,  the  glands  give  a  sensation  of  firmness  and 
elasticity,  which  is  due  to  the  fact  that  the  interfoUicular 
and  deep  fibro-cellular  tissue  is  increased.  In  rare  cases,  only 
a  single  tonsil  is  involved  in  chronic  hypertrophy  ;  more  often 
both  are  similarly  enlarged,  although  one  may  be  more  so  than 
its  fellow.  The  symptoms  of  enlargement  of  the  tonsils  are 
usually  so  apparent  as  to  be  unmistakable.  If  the  enlarge- 
ment is  considerable,  it  causes  the  child  to  snore ;  it  modifies 
the  voice  ;  and  produces  a  frequent  cough,  and  occasionally 
gives  rise  to  deafness  by  the  pressure  on  the  eustachian  tubes, 
and  the  associated  hypertrophic  or  inflammatory  changes 
which  it  invites  in  the  surrounding  mucous  membrane.  In 
some  cases  it  so  obstructs  respiration  as  to  distort  the  chest, 
which  becomes  "  pigeon  breasted,"  from  the  failure  to  prop- 
erly inflate  the  lungs,  and  so  oppose  the  influence  on  the  ribs 
of  outside  atmospheric  pressure. 

Treatment. — The  treatment  of  chronic  hypertrophy  of  the 
tonsils  is  not  very  satisfactory.  Whether  this  is  due  to  the 
inefficiency  of  remedies,  or  to  the  lack  of  persistence  in  their 
employment,  is  an  open  question.     In  bad  cases,  undoubtedly 


532  THE  DISEASES  OF  CHILDREN. 

excision  is  the  only  reliable  remedy,  and  time  is  wasted  in  pro- 
crastination. The  fact  that  the  disease  is  never  fatal,  and 
that  as  age  advances  there  is  a  chance  of  spontaneous  im- 
provement, renders  parents  very  repugnant  to  an  operation 
that  may  be  postponed  or  in  course  of  time  become  un- 
necessary. 

As  the  victims  of  the  disease  are  generally  weak  and  physi- 
cally ill-favored,  the  first  efforts  given  to  amelioration  or  cure 
should  be  addressed  to  the  general  health. 

The  sanitary  surroundings  of  the  patient  should  be  improved, 
and  fresh  air  and  sunshine  recommended.  The  diet  should  be 
wholesome  and  nutritious.  To  children  of  the  strumous  habit, 
cod-liver  oil  should  be  given,  with  daily  baths  of  salt  water 
moderately  cold,  with  brisk  general  frictions  of  the  entire  body. 
Everything  should  be  done  to  improve  the  general  health.  In 
addition  to  this,  it  is  said  that  much  good  may  be  accomplished 
by  teaching  the  child  to  press  upon  the  tonsils  with  the  finger 
for  a  few  minutes  daily.  In  infants  and  young  children  this 
may  be  done  by  the  mother  or  nurse.  We  have  never  had 
much  success  with  local  measures,  such  as  painting  the  tonsils 
with  iodine  or  astringent  lotions. 

We  have  had  good  results  in  some  cases  with  the  internal  ad- 
ministration oi  fucusves.,  given  in  tincture  of  one  to  three  drops 
three  times  daily,  in  sweetened  water  or  on  sugar.  We  have 
also  seen  good  results  in  a  few  cases  from  calc.  iod.  jx  and 
fnerc.  iod.  jx^  given  thrice  daily,  and  kept  up  for  many  weeks. 
Where  the  chronic  hypertrophy  is  accompanied  with  a  dis- 
charge of  cheesy  and  offensive  matter  from  the  tonsilar  follicles, 
kali  bichromicum  is  a  useful  medicine.  Arndt  and  others  speak 
highly  of  baryta  carb.  and  baryta  iodatus. 

RETRO-PHARYNGEAL  ABSCESS. 

A  very  infrequent  but  occasionally  occurring  disease  some- 
times attacks  the  submucous  tissues  of  the  pharynx,  and  is  at- 
tended with  inflammation  which  results  in  the  formation  of 
pus.  It  is  a  disease  that  may  occur  at  all  ages,  but  is  most 
commonly  met  with  in  young  infants.  In  some  cases  the  cause 
is  traumatism,  and  follows  a  wound  from  swallowing  bones, 
pins  or  other  foreign  substances.  At  other  times  the  disease  is 
idiopathic,  and  is  due  to  cold  affecting  scrofulous  or  syphilitic 
subjects.  The  symptoms  are  not  always  well  defined,  and  may 
be  mistaken  for  those  of  enlarged  tonsils.  There  is  deep-seated 
pain  in  the  pharynx,  which  is  especially  noticeable  when  swal- 
lowing is  attempted.  The  neck  i's  stiff,  and  the  head  is  held  on 
one  side  in  a  peculiar  and  fixed  position.   There  are  spasmodic 


RETRO-PHARTNGEAL  ABSCESS.  533 

attacks  of  dyspnea,  and  sometimes  there  are  convulsions. 
When  the  disease  is  idiopathic,  it  may  develop  in  the  course  of 
forty-eight  hours ;  but  when  it  is  secondary  to  scarlatina  or 
acute  pharyngitis,  it  generally  takes  from  seven  to  ten  days  to 
develop.  When  occasioned  by  caries  of  the  spine,  its  progress 
is  still  more  slow  and  indefinite.  The  first  noticeable  symp- 
toms are  pain  on  deglutition,  which  becomes  more  pronounced 
as  the  disease  progresses,  until,  if  the  abscess  be  large,  swallow- 
ing is  rendered  impossible.  An  inspection  of  the  throat  re- 
veals a  round,  bulging  tumor  in  the  fauces,  which  is  firm  and 
elastic  to  the  touch.  Sooner  or  later  distinct  fluctuation  will 
be  present,  and  as  soon  as  this  is  apparent  there  should  be  no 
delay  in  opening  the  abscess  and  evacuating  its  contents.  This 
is  imperatively  demanded,  for  if  the  abscess  be  permitted  to 
open  spontaneously,  it  may  happen  at  inopportune  times,  as 
when  the  child  is  asleep,  and  pus  be  sucked  into  the  lungs, 
causing  death  from  suffocation.  The  incision  should  be  verti- 
cal, with  a  guarded  bistoury,  all  but  the  point  being  encased  in 
strapping. 


CHAPTER  V. 

LARYNGITIS  (SPASMODIC  CROUP,    FALSE   CROUP,    CATARRHAL 

LARYNGITIS). 

Spasmodic  Laryngitis. — This  affection  of  the  larynx  is 
most  frequently  met  with  in  children  during  first  dentition,  and 
especially  during  the  second  year  of  life.  It  is  common,  also, 
up  to  six  or  seven  years  of  age,  and  the  tendency  to  it  some- 
times persists  till  the  fifteenth  or  sixteenth  year.  Like  other 
inflammatory  affections  of  the  air-passages,  it  is  most  common 
during  the  cold  months,  and  in  changeable  weather.  It  some- 
times accompanies  the  eruptive  fevers,  and  also  bronchitis  and 
pharyngitis.  In  the  latter  case  it  is  due  to  an  extension  of  the 
primary  inflammation  downward.  Its  remote  causes  are  gas- 
tric derangements  and  heredity.  Some  families  are  very  prone 
to  it ;  and  some  children  are  subject  to  repeated  attacks.  We 
have  a  case  in  mind  of  a  child  who,  from  two  to  six  years  of 
age,  had  an  attack  of  spasmodic  croup  whenever  the  wind  veered 
around  suddenly  and  blew  from  the  east.  The  exciting  cause 
is  usually  a  sudden  chilling  of  a  portion  of  the  body,  or  expo- 
sure to  dampness  and  cold.  It  sometimes  has  no  prodromal 
symptom,  coming  on  suddenly  toward  midnight,  after  several 
hours  of  natural  and  undisturbed  sleep. 

More  often,  however,  the  attack  is  preceded  by  more  or  less 
coryza,  and  by  hoarseness,  which  is  apparent  when  the  child 
cries,  or  if  old  enough,  when  it  attempts  to  speak.  Occasion- 
ally there  is  complete  loss  of  voice,  so  that  speech  above  a 
whisper  is  impossible.  There  may  have  been  some  cough  dur- 
ing the  preceding  day,  which  tightens  up  as  night  approaches. 
But  in  a  typical  case,  the  child  goes  to  bed  without  fever  or 
anything  in  the  way  of  ill-health  to  attract  attention.  After  a 
short  sleep,  it  awakens  with  a  shrill,  ringing  cough,  which  is 
variously  described  as  "  brassy,"  or  "  clanging."  There  is  more 
or  less  oppression  about  the  chest,  and  difficulty  of  breathing. 
Inspiration  is  prolonged,  stridulous,  and  crowing.  The  child 
exhibits  fear  and  anxiety,  wishes  to  be  taken  up,  and  if  the 
bre'athing  is  much  impeded,  breaks  out  into  a  cold  perspiration. 
If  an  attempt  be  made  to  speak,  it  is  found  that  the  voice  is 
lost,  and  only  a  whisper  remains.  The  dypsnea  is  often  very 
great,  but  the  gravity  of  the  symptoms  is  out  of  all  proportion 
(534) 


CHRONIC  LARTNGITIS.  535 

to  that  of  the  disease  itself.  The  difficulty  is  manifestly  spas- 
modic, for  often  the  child  will  soon  be  appeased,  the  spasm 
passes  away,  and  he  drops  off  into  a  quiet  sleep,  which  is  inter- 
rupted again  and  again  at  variable  intervals  by  a  repetition  of 
the  "  croupy  cough."  If  left  to  itself,  this  experience  will  be 
repeated  on  the  two  suceeding  nights,  for  spasmodic  laryngitis 
inclines  to  run  a  course  of  three  days.  During  this  time  the 
cough  remains  croupy,  but  gives  but  little  trouble  during  the 
daytime.  At  the  end  of  from  three  to  five  days,  or  sooner, 
the  voice  is  quite  restored,  the  cough  disappears,  and  the  child 
is  quite  well  again. 

Diagnosis. — The  only  disease  that  could  be  confounded  with 
spasmodic  laryngitis  is  that  more  formidable  disease,  to  be  de- 
scribed later  on,  viz.:  true  croup.  In  most  cases,  however, 
there  need  be  no  confusion.  The  sudden  onset  of  the  attack; 
the  previous  coryza;  the  absence  of  persistent  inspiratory 
stridor,  and  the  speedy  subsidence  of  the  momentary  fear  and 
restlessness,  indicating  a  passing  spasm,  will  serve  to  show  that 
the  disease  is  a  transient  and  trivial  disorder,  and  not  one  im- 
periling life  from  suffocation.  This  differential  diagnosis  will 
be  made  more  plain  when  speaking  of  the  graver  disease. 

Treatment. — These  attacks  frequently  pass  off  after  the  usual 
exhibition  of  domestic  remedies,  one  of  the  best  of  which  is  a 
half-teaspoonful  of  warm  vaselin.  This  seldom  fails  to  give 
prompt  relief  from  the  immediate  spasm,  and  other  and  more 
scientific  treatment  can  then  be  given  to  anticipate  or  prevent 
the  attack  on  the  succeeding  night.  As  a  prophylaxis,  the 
child  who  is  subject  to  spasmodic  croup  should  be  warmly  clad 
and  be  kept  in  a  warm,  dry,  sunny  atmosphere. 

While  the  attack  is  present,  the  child  should  be  kept  in  bed  in 
a  warm  room,  and  if  the  attack  is  at  all  obstinate,  the  air  should 
be  moistened  with  a  steam  atomizer  or  a  bronchitis  kettle. 
Flaxseed  poultices  or  hot  fomentations  applied  to  the  throat 
will  help  to  shorten  the  paroxysm  and  prevent  a  speedy  repe- 
tition. 

In  the  matter  of  internal  remedies,  Boenninghausen's  aconite, 
spongia  and  hepar  sulphur  are  famous  the  world  over.  Few 
cases  will  be  found  to  resist  them.  The  latter  alone  will  often 
be  found  quite  sufficient.  Kali  bichromicum,  ipecac,  tartar 
emetic,  bromin  and  sambucus  are  also  remedies  that  have  their 
advocates,  and  may  be  used  according  to  their  indications. 

Chronic  Laryngitis  is  of  very  rare  occurrence  in  child- 
hood, and  when  it  does  occur,  it  is  generally  of  syphilitic  origin. 

There  is  persistent  hoarseness,  sometimes  amounting  to 
aphonia.      There  is  lacking  the  fever  attendant   upon  acute 


536  THE  DISEASES  OF  CHILDREN. 

laryngitis,  but  otherwise  the  symptoms  are  similar,  but  of  less 
severity,  except  as  an  acute  attack  is  grafted  into  the  chronic 
condition.  When  this  is  the  case,  the  child  is  placed  in  great 
peril,  and  tracheotomy  or  intubation  frequently  offers  the  only 
recourse.  There  is  always  danger  in  these  cases  of  permanent 
thickening  of  the  laryngeal  tissues,  and  of  warty  growths  within 
the  larynx.  The  treatment,  aside  from  relieving  the  dyspnea  by 
measures  already  mentioned,  should  be  addressed  to  the  dys- 
crasia  underlying  the  local  disease,  as  laid  down  under  the 
head  of  Infantile  Syphilis. 

Laryngeal  Spasm — Laryngismus  Stridulus.— In  addi- 
tion to  the  laryngeal  affections  already  mentioned,  there  is  one 
occasionally  met  with  in  which  there  is  no  inflammation,  and 
no  local  lesion  discernible,  and  yet  it  is  accompanied  with 
great  dyspnea  and  catching  of  the  breath,  and  may  even  prove 
fatal.  It  is  often  associated  with  rickets,  but  may  occur  idio- 
pathically.  It  is  to  all  intents  and  purposes  a  nervous  or  spas- 
modic affection  of  the  larynx,  and  involves  more  especially  the 
glottis  and  epiglottis. 

As  Edmonds  says,  "  It  might  with  much  propriety  be  called 
an  asthma  of  the  larynx."  It  is  sometimes  spoken  of  by 
authors  and  the  laity  as  "  internal  convulsions." 

The  essential  feature  of  the  disease  consists  in  the  child  hold- 
ing its  breath,  or  being  unable  to  catch  its  breath,  until  the 
face  becomes  livid  and  suffocation  seems  inevitable.  West  thus 
describes  an  attack  :  "  The  child  throws  its  head  back,  its  face 
and  lips  become  livid,  or  an  ashy  pallor  surrounds  the  mouth,, 
and  slight  convulsive  movements  pass  over  the  muscles  of  the 
face  ;  the  chest  is  motionless  and  suffocation  seems  impending^ 
But  in  a  few  moments  the  spasm  yields,  expiration  is  effected, 
and  the  crowing  inspiration  succeeds." 

The  crowing  sound  which  thus  terminates  these  attacks  has 
given  the  disease  the  vulgar  name  of  "  child  crowing." 

The  spasm  is  essentially  reflex  in  its  nature,  and  is  frequently 
caused  by  some  irritation  of  the  mediastinal  nerves.  It  is 
brought  on  by  sudden  excitement,  or  anything  which  hurries 
the  breathing.  The  attack  is  associated  with  a  sort  of  wheeze, 
which  is  something  between  the  whoop  of  pertussis  and  the 
stridor  of  true  croup.  The  attack  may  not  last  more  than  a 
minute,  or  even  less,  and  the  crow  over,  there  is  perhaps  a  fit 
of  crying,  when  the  child  drops  to  sleep  or  goes  on  with  its 
play  as  if  nothing  had  happened.  In  some  of  these  cases,  there 
has  been  found  to  be  an  enlargement  of  the  bronchial  glands, 
but  this  is  by  no  means  uniform.  The  causes  of  laryngismus 
are  various.     It  is  so  often  associated  with  rickets  that  some 


LARYNGEAL  SPASM.  537 

writers  have  stated  that  there  is  never  one  of  these  diseases 
without  the  other.  This  is  certainly  a  mistake,  for  we  have 
seen  at  least  three  cases  in  our  private  practice  in  which  there 
was  not  the  slightest  indication  of  rickets. 

Goodhart  considers  that  this  affection,  or  one  quite  analo- 
gous to  it,  which  he  calls  "  infantile  spasm  of  the  larynx,"  is 
due  oftentimes  to  a  "  congenital  recurvation  of  the  epiglottis, 
which  is  a  common  thing  in  infancy  and  early  childhood." 
Whatever  the  cause  operating  in  a  given  case,  the  affection 
is  not  attended  with  the  real  danger  that  the  symptoms  indi- 
cate. When  due  to,  or  associated  with,  general  convulsions, 
there  is  genuine  danger,  for  there  is  not  in  such  cases  the  same 
response  to  stimuli  that  is  present  when  convulsions  are  ab- 
sent. In  most  of  these  cases  the  spasms  are  ultimately  out- 
grown, or  disappear  as  the  child  becomes  older,  for  the  disease 
is  purely  infantile  in  its  expression. 

Treatment. — When  laryngismus  is  associated  with  rickets,  or 
enlarged  bronchial  glands,  the  treatment  must  have  reference 
to  the  constitutional  dyscrasia.  Change  of  air,  a  sojourn  at 
the  seaside,  cod-liver  oil,  calc.  phos.,  and  remedies  already  men- 
tioned under  the  head  of  Rickets,  will  be  of  service.  For  the 
relief  of  the  spasm  itself,  the  inhalation  of  some  quick  acting 
stimulant  is  required.  Nitrite  of  amy  I ,  chloroform  or  aromatic 
spirits  of  ammonia  will  answer  the  purpose.  For  internal 
administration,  with  a  view  of  breaking  up  the  habit  and  pre- 
venting a  repetition  of  the  spasms,  belladonna,  hyoscyamuSy 
cuprum  and  especially  gelsemium^  will  be  found  of  value. 


CHAPTER  VI. 

ACUTE      MEMBRANOUS      LARYNGITIS      (PSEUDO-MEMBRANOUS 
LARYNGITIS)  ;   TRUE  CROUP. 

This  form  of  laryngitis,  commonly  known  as  "  membranous 
croup,"  differs  from  all  other  forms  of  laryngeal  inflammation 
in  being  characterized  by  the  formation  within  the  larynx  or 
trachea  of  a  fibrinous  pseudo-membrane.  It  occurs  most  fre- 
quently between  the  ages  of  two  and  twelve,  but  no  age  is  com- 
pletely exempt  from  it.  It  is  rarely  met  with  under  six  months 
of  age,  and  is  not  common  after  puberty. 

It  is  one  of  the  most  fatal  of  infantile  diseases. 

This  form  of  laryngitis  is  so  often  associated  with  diphtheria 
that  many  authors  refuse  to  consider  it  as  having  other  than  a 
diphtheritic  origin.  It  is  conceded  on  all  hands  that  the  diph- 
theritic membrane  may  originate  in  the  larynx,  or  the  trachea, 
without  showing  any  exudation  on  the  tonsils  or  on  the  fauces, 
and  that  many  cases  of  croup  are  genuine  cases  of  diphtheria. 
In  other  words,  no  one  disputes  the  fact  that  there  may  be,  and 
are,  many  cases  of  diphtheritic  croup  in  which  there  are  no 
other  visible  evidences  of  the  disease  than  are  afforded  by  the 
croupy  manifestations. 

When  diphtheria  has  once  manifested  itself  in  the  pharynx, 
and  thence  extended  into  larynx  or  trachea,  there  can  be  no  ques- 
tion as  to  the  nature  of  the  inflammation  there  set  up.  But 
when  the  primary  disease  is  below  the  epiglottis,  and  when 
there  is  an  entire  absence  of  any  history  of  exposure  to  the 
diphtheritic  contagium,  the  case  is  different.  It  is  in  such  cases 
that  the  question  arises — Is  there  such  a  thing  as  membranous 
laryngitis  independent  of  diphtheria  ?  Our  own  answer  to  the 
question  is  emphatically  in  the  affirmative.  We  recognize  two 
distinct  and  separate  forms  of  croup — the  specific  and  the  non- 
specific ;  or,  lest  our  words  may  be  misunderstood,  a  diptheritic 
and  a  non-diphtheritic  croup.  Let  the  grounds  for  this  belief 
be  briefly  stated.  In  the  first  place,  it  is  a  well-established  fact 
that  inflammation  of  the  laryngeal  and  tracheal  surface,  when- 
ever it  reaches  a  certain  grade  of  severity,  is  very  sure  to  be 
attended  by  the  exudation  of  fibrin  and  the  formation  of  a 
pseudo-membrane.  This  has  been  repeatedly  observed  in  cases 
of  inflammation  in  these  localities  produced  by  the  inhalation 
(538) 


ACUTE  MEMBRANOUS  LARYNGITIS.  539 

of  superheated  steam,  or  hot  smoke.  Surely  in  such  cases  there 
could  be  no  suspicion  of  specific  origin.  Then,  again,  we  see 
cases  of  croup,  with  all  its  attendant  phenomena,  as  a  compli- 
cation in  measles,  pertussis,  scarlatina,  and  even  in  typhoid 
fever,  when  there  is  no  indication  whatever  that  there  is  a  diph- 
theritic element  present.  The  clinical  history  of  the  two  dis- 
eases fails  to  bear  out  the  theory  that  they  are  in  any  sense 
identical. 

Diphtheria  is  adynamic  or  asthenic  from  the  beginning,  while 
croup  becomes  so  only  towards  the  termination  of  fatal  cases. 
The  one  is  contagious,  the  other  is  not. 

Membranous  croup  always  begins  with  decided  laryngeal 
symptoms,  and  the  attendant  exudation  is  by  preference  in  the 
larynx.  If  in  membranous  croup  there  be  a  visible  exudate  in 
the  pharynx,  or  on  the  soft  palate,  or  uvula,  it  is  from  an  ex- 
tension of  the  membrane  upwards. 

In  diphtheria  the  membrane  exhibits  a  preference  for  the 
pharynx,  and  it  is  generally,  nearly  always,  hours  or  days  be- 
fore the  exudation  involves  the  larynx. 

Diphtheritic  croup  is,  therefore,  a  secondary  affection,  while 
true  membranous  croup  is  a  primary  one. 

Diphtheria  occurs  endemically  or  epidemically,  while  croup  is 
usually  sporadic,  affecting  only  here  and  there  an  individual 
and  showing  no  contagious  or  infectious  properties  or  tenden- 
cies. But  the  reader  is  referred  to  the  chapter  on  Diphtheria, 
where  the  essential  features  of  the  two  diseases  are  placed  side 
by  side  in  tabulated  form.  We  cannot  see  how  any  unpreju- 
diced mind  can  fail  to -discern  the  wide  difference  between  the 
two  in  all  essential  particulars,  or  refuse  to  admit  that  there  is  a 
croup  which  is  a  local  disease,  non-specific,  and  quite  distinct 
from  the  croup  of  diphtheria.  It  is  with  this  latter  that  we 
have  now  to  deal. 

True  croup  is  a  disease  of  childhood  rather  than  infancy,  and 
yet  infants  are  by  no  means  exempt  from  its  ravages.  It  is 
more  common  after  the  first  year  than  before,  and  boys  are 
said  to  be  more  often  affected  than  girls,  in  the  proportion  of 
three  to  two.  It  is  more  prevalent  in  winter  and  spring  than 
in  summer  and  autumn. 

A  cold,  damp  wind,  especially  if  from  the  east  or  northeast, 
greatly  favors  it.  Unlike  catarrhal  or  false  croup,  true  croup 
does  not  tend  to  recur.  Stiener,  who  has  had  an  experience 
covering  100,000  cases,  states  that  he  has  never  known  the  dis- 
ease to  occur  twice  in  the  same  individual.  All  clinical  expe- 
rience tends  to  show  that  the  exciting  cause  of  the  disease  is 
exposure  to  cold  and  dampness. 

Symptoms. — The  early  symptoms  of  true  croup  are  insidious. 


540  THE  DISEASES  OF  CHILDREN. 

The  child  may  have  a  croupy  cough  for  several  days  before 
there  is  any  marked  dyspnea;  but  a  slight  hoarseness  or  huski- 
ness  of  voice,  that  is  scarcely  noticeable  at  first,  increases  from 
day  to  day,  or  perhaps  from  hour  to  hour,  until,  if  unrelieved 
by  medical  treatment,  there  is  complete  aphonia. 

In  the  early  stages  there  is  no  fever  to  speak  of,  and  the 
child  plays  about  as  usual  during  the  day.  At  night,  however, 
its  sleep  is  disturbed  by  a  ringing  bark  of  a  cough,  which  has  a 
decided  metallic  or  brassy  sound.  This  cough  recurs  at  irregu- 
lar intervals,  and  there  is  a  steady  but  slow  progression  of  the 
hoarseness.  There  is  a  marked  tendency  to  aggravation  at  or 
just  before  midnight,  in  this  respect  resembling  simple  or  ca- 
tarrhal laryngitis.  In  some  cases  the  fauces  are  injected,  either 
from  the  effects  of  the  cough  or  from  diffuse  inflammation.  As 
the  disease  progresses,  the  respirations  become  noisy  and  la- 
bored, the  face  becomes  flushed  and  takes  on  a  look  of  anxiety. 
An  inspection  of  the  chest  will  reveal  the  fact  that  at  each 
inspiration  the  post-clavicular,  supra-sternal  and  infra-mammary 
regions  are  depressed.  The  breathing  becomes  audible,  and 
has  a  sawing  sound  that  may  be  heard  at  a  considerable  dis- 
tance. There  is  usually  no  coryza  in  these  cases.  On  the  con- 
trary, the  throat  and  nasal  mucous  membranes  are  usually  dry 
and  somewhat  injected.  Sometimes  the  redness  is  slight  and 
sometimes  quite  marked.  On  the  second  or  third  day,  the 
disease  progressing  all  the  time,  the  dyspnea  increases,  and 
there  is  some  febrile  movement,  although  at  no  time  is  the 
temperature  high. 

When  the  obstructive  membrane  in  the  larynx  or  trachea  has 
reached  a  certain  stage,  the  appearance  of  the  child  is  very 
characteristic.  Distress  is  pictured  on  every  feature.  The  eyes 
stare ;  the  face  is  red  or  by  turns  purple.  The  inspirations 
are  prolonged,  and  decidedly  stridulous.  The  child  clutches  at 
his  throat,  as  if  with  his  fingers  he  could  aid  his  struggles  for 
breath.  Every  effort  at  coughing  produces  a  characteristic 
ringing  sound,  which,  after  a  time,  loses  volume,  until  it  is  lost 
in  a  wheeze  or  becomes  inaudible.  The  attacks  of  dyspnea  are 
paroxysmal,  and  may  last  for  a  few  moments,  or  in  exceptional 
cases,  for  a  half-hour  or  more.  There  is  manifestly  a  recurrent 
spasm  of  the  glottis,  which  adds  to  the  distressful  breathing. 
There  is  great  restlessness  after  the  respirations  have  become 
seriously  embarrassed.  The  child  is  constantly  changing  posi- 
tion and  place — now  wanting  to  be  carried,  and  now  to  be  put 
back  to  bed.  At  intervals,  suffocative  attacks  occur,  when 
Lisphyxia  seems  to  be  inevitable.  The  inability  to  carry  on  the 
respiratory  function  at  last  produces  its  inevitable  result,  and 
the  blood  becomes  loaded  with  carbonic  acid.     This  is  evi- 


ACUTE  MEMBRANOUS  LARVNGITIS.  541 

denced  by  the  blueness  of  the  lips,  the  pallor  of  the  face,  and 
the  dullness  of  the  sensibiHties.  The  expression  of  the  face 
loses  its  anxiety  and  fear,  and  a  look  of  dullness  and  indiffer- 
ence takes  their  place.  The  respirations  are  more  quiet  and 
superficial.  The  stridor  disappears,  but  there  are  frequent 
struggles  for  breath,  followed  by  exhaustion  and  a  lapse  into  a 
comatose  or  semi-comatose  condition. 

Dr.  J.  S.  Mitchell,  in  his  able  monogram  on  this  disease, 
published  in  Arndt's  "System  of  Medicine,"  says  under  the  head. 
Special  Symptoms  —  Breathing:  "The  peculiar  breathing  of 
croup,  which  gives  it  its  distinctive  character,  and  which  has 
the  sound  which  is  most  dreaded  by  the  parents  and  physician, 
is  due  to  the  fact  that,  notwithstanding  the  labored  breathing, 
only  a  small  quantity  of  air  is  able  to  pass  through  the  narrow 
glottis.  There  is  prolonged  inspiration,  and  a  wheezing,  whis- 
tling snoring  sound,  sometimes  heard  for  a  long  distance.  It  has 
a  sibilant,  tubular,  metallic  quality,  and  its  pitch  is  high.  In 
one  case  which  was  under  my  charge,  it  was  scarcely  possible  to 
find  any  part  of  the  house  so  distant  that  the  distressing  sound 
could  not  be  heard.  The  expiration  is  marked,  and  accompa- 
nied by  the  rattling  of  mucus,  and  is  distinguished  from  *he 
sharper  and  sawing  nature  of  the  inspiratory  sound,  by  its  low 
tone  and  snoring  quality.  The  breathing  usually  continues  to 
manifest  these  characteristics  from  the  time  the  second  stage 
is  reached  until  the  end,  or  until  there  has  been  relief  to  the 
dyspnea. 

"  The  respiratory  sounds  are  also  distinctive  ;  they  are  notably 
deficient,  but  if,  during  the  prevalence  of  dyspnea,  they  become 
increased  in  frequency,  they  are  not  effective.  The  supra-clav- 
icular spaces  are  depressed  during  inspiration  ;  the  intercostal 
spaces  do  not  bulge,  nor  do  the  chest  walls  expand  to  the 
normal  extent.  The  inspiratory  retraction,  which  has  been  be- 
fore noticed,  is  significant  of  marked  dyspnea.  The  febrile 
movement  is  not  marked  after  the  first  or  second  day.  The 
temperature  may  rise  as  high  as  102°  or  103°,  but  ordinarily  it 
will  be  found  to  be  about  100°,  and  on  the  third,  or  at  least  the 
fifth  day,  it  will  subside.  In  those  cases  where  it  is  found  up 
to  104°  or  105  8-10°,  we  shall  find  that  extensive  bronchitis  or 
pneumonia  exists.  The  pulse,  early,  is  full,  hard,  and  from 
120  to  130.  In  the  second  stage  it  continues  at  about  this  rate, 
except  that  during  the  suffocative  spells  it  may  rise  20  or  30 
beats  ;  in  the  last  stage  it  becomes  very  rapid,  160,  or  even  180, 
small,  compressible,  and  intermittent.  A  persistent  high  tem- 
perature is  significant  either  of  diphtheria  or  catarrhal  laryngitis. 

"  The  dyspnea  is  one  of  the  evidences  of  the  disease.  It  is 
the  result  of  the  laryngeal  stenosis,  and  marks  the  advance  of 


542  THE  DISEASES  OF  CHILDREN. 

the  second  stage.  The  respirations  rise  from  28  to  32  per 
minute,  sometimes  more  ;  all  the  accessory  muscles  are  brought 
into  play.  The  child  throws  the  head  upward  with  each  res- 
piration, somewhat  after  the  manner  of  the  asthmatic.  His 
whole  efforts  are  bent  on  expanding  the  chest.  The  inspirations 
grow  more  labored  as  the  laryngeal  contraction  increases ;  the 
mouth  is  opened  widely.  The  alae  nasi  now  contract,  and  again 
are  widely  open  ;  the  larynx  is  depressed  after  each  inspiration, 
and  the  cartilages  of  the  lower  ribs  are  drawn  inwards. 

"  Different  opinions  have  been  expressed  as  to  the  cause  of 
this  dyspnea.  Niemeyer  has  advanced  the  view  that  it  is  de- 
pendent mainly  upon  paralysis  of  the  laryngeal  muscles.  He 
regards  this  paralysis  as  the  result  of  the  infiltration  of  the 
mucous  and  submucous  tissues,  which  exerts  pressure  upon  the 
muscles  and  renders  them  sodden  and  powerless.  An  important 
clinical  fact  is  brought  out  by  this  consideration,  for  in  paraly- 
sis of  the  laryngeal  muscles  inspiration  is  affected,  being  ren- 
dered prolonged  and  stridulous,  while  the  expiration  is  easy  ; 
difficulty  in  both  inspiration  and  expiration  indicates  that  there 
is  an  exudation,  or  a  contraction  of  the  glottis  from  edema. 

"  I  once  had  an  opportunity  to  make  a  post-mortem  exami- 
nation in  the  case  of  a  child  that  had  died  from  a  severe  attack 
of  false  croup,  which,  throughout  its  history  of  eleven  days, 
simulated  constantly  the  symptoms  of  membranous  croup, 
with  the  exception  that  there  was  at  no  time  evidence  of  exu- 
dation. He  had,  however,  every  other  symptom  characteristic 
of  membranous  croup.  The  child  died  during  one  of  the  suf- 
focative attacks.  There  was  no  evidence  of  any  membrane  in 
the  larynx,  nor  was  there  any  evidence  of  the  severe  dyspnea 
to  which  the  child  had  been  subjected  ;  there  was  a  slight  trace  of 
edema  glottidis,  but  entirely  insufficient  to  account  for  the  dysp- 
nea and  prolonged  stridor.  The  parts  were  not  hyperemic, 
though,  of  course,  this  is  explained  by  the  well-known  fact  that 
the  laryngeal  mucous  membrane  is  rich  in  elastic  fibers,  and  we 
often  find  it  free  from  hyperemia  after  death,  when  previous 
laryngoscopic  examination  had  shown  an  intense  degree  of  con- 
gestion. This  case  of  stridor  and  dyspnea,  which  was  worse 
upon  inspiration,  was  undoubtedly  due  to  inflammatory  exten- 
sion, so  far  affecting  the  muscles  as  to  interfere  with  their 
proper  action.  There  was  no  evidence  that  the  difficulty  was 
in  any  way  due  to  central  nervous  lesion. 

"  Rudnicky  *  claims  that  the  dyspnea  of  croup  is  due  to  lack 
of  coordination  of  the  respiratory  movement  from  nervous  irri- 
tation.    He  insists  that  there  is  a  special  disturbance  of  the 


*  Wirner,  Med.  WockeHschrift,  Nos.  323,  324,  325,  1873. 


ACUTE  MEMBRA  NO  US  LAR  TN  GI TIS.  548 

nerves,  and  that  it  may  be  outside  the  larynx.  He  refers  to  the 
fact  that  the  branches  of  the  superior  laryngeal  and  recurrent 
nerves  have  many  ganglionic  cells,  which  are  provided  before 
their  separation  into  muscular  subdivisions.  They  are  true 
ganglia,  from  which  distinct  bands  of  nerve  fibers  may  extend 
to  the  muscular  layers  of  the  larynx.  Rudincky  contends  that 
Niemeyer's  theory  is  not  correct,  as  was  evidenced  from  laryn- 
goscopic  examinations  which  he  made,  demonstrating  that  the 
vocal  cords  move  as  usual  during  the  existence  of  croup,  thus 
showing  that  there  could  be  no  paralysis.  Ziemssen  (vol.  iv.,  p. 
242),  regards  the  dyspnea  of  croup  as  the  combined  result  of 
several  causes,  acting  together  or  in  succession,  the  most  com- 
mon of  which  is,  undoubtedly,  a  mechanical  one,  namely,  the 
swollen,  relaxed  and  intensely-congested  state  of  the  mucous 
membrane  of  the  larynx,  on  the  one  hand,  and  the  false  mem- 
brane and  muco-purulent  secretion  on  the  other.  He  says  that 
everyone  who  has  had  frequent  opportunities  for  observation 
after  death  of  the  anatomical  changes  in  the  larynx  of  children, 
and  who  considers  how  little  is  needed  to  block  up  the  glottis 
in  such  patients,  must  be  justified  in  inferring  the  intimate 
causal  connection  between  the  dyspnea  of  croup  and  the 
changes  referred  to.  He  cites  cases  in  which  the  most  marked 
dyspnea  is  observed  in  children  during  life,  without  any  croup- 
ous membrane  being  found  after  death,  and  in  which  the  ana- 
tomical changes  are  out  of  proportion  to  the  symptoms  of  the 
stenosis  ;  he  states  that  in  more  than  one  hundred  cases  of  fatal 
croup  among  children,  he  has  been  always  able  to  find  the  false 
membrane  in  the  larynx,  though,  of  course,  more  intensely  and 
more  widely  developed  in  some  cases  than  others.  But  the  sin- 
gle case  to  which  I  have  just  referred,  shows  that  a  fatal  dysp- 
nea may  obtain  without  the  presence  of  slightest  amount 
of  exudation.  This  shows  that  even  in  true  croup  it  is  not 
necessary  that  the  exudation  must  be  the  sole  cause  of  the 
dyspnea,  and  we  may  reasonably  believe  that  if  we  can  control 
the  Oedema  and  the  spasm  of  the  glottis,  we  may  apprehend 
comparatively  little  danger  from  the  exudate,  unless  its  quan- 
tity be  so  great  as  to  completely  fill  up  the  larynx. 

"In  one  case,  which  I  had  the  opportunity  of  examining 
through  the  kindness  of  Dr.  S.  P.  Hedges,  the  larynx  was  com- 
pletely filled  with  a  tough,  fibrous  exudate,  so  that  it  would 
apparently  have  been  impossible  for  the  smallest  quantity  of 
air  to  enter.  Indeed,  it  seemed  as  if  the  exudate  and  laryngeal 
structures  were  simply  one  solid  mass. 

"A  therapeutic  hint  may  be  obtained  here.  The  treatment 
undoubtedly  should  be  directed  more  specially  to  the  stenosis, 
with  the  presumption  that  it  is  the  result  of  the^dema  of  the 


544  THE  DISEASES  OF  CHILDREN. 

glottis  and  spasm  of  the  glottis,  rather  than  of  the  presence  of 
the  exudate.  It  is  a  well-known  fact  that  after  tracheotomy, 
the  dyspnea  sometimes  continues  as  urgent  as  before,  the  lar- 
ynx being  then  no  longer  a  portion  of  the  respiratory  apparatus. 

^'Remissions. — These  occur  in  those  cases  of  croup  which  are 
characterized  by  a  moderate  course.  There  are  instances  where 
distinct  remissions  occur  in  the  second  stage.  There  is  a 
marked  improvement  in  the  dyspnea,  although  it  does  not  dis- 
appear wholly.  There  is  also  a  remission  of  the  cough,  the 
voice  becomes  more  natural,  and  we  find  an  improvement  in 
the  general  condition  of  the  patient.  The  febrile  movement  is 
almost  entirely  gone,  and  the  appetite  partially  or  wholly  re- 
turns, and  there  is  a  disposition  to  sleep.  These  remissions  are 
very  favorable,  especially  when  they  are  attended  by  an  exfo- 
liation of  a  certain  portion  of  the  false  membrane,  which  may 
be  thrown  off  in  small  masses  mingled  with  mucus,  or  in  irregu- 
lar masses,  sometimes  in  the  form  of  tubular  casts  of  the  part. 
If  these  exfoliations  continue,  the  remissions  indicate  that  there 
will  probably  be  a  favorable  termination  of  the  disease,  there  is 
a  longer  period  between  the  suffocative  spells ;  and  the  dyspnea 
is  markedly  diminished.  The  cough  grows  looser,  and  the  ex- 
pectoration of  mucus,  or  a  muco-purulent  secretion  mixed  with 
the  flakes  of  fibrin,  increases.  The  voice  becomes  less  and  less 
hoarse,  and  the  fever  stops  entirely,  perspiration  occurs,  the 
patient  becomes  more  cheerful  and  natural,  and  the  case  turns 
into  one  of  simple  laryngeal  catarrh. 

"  But  many  times  these  remissions  are  delusive ;  the  suffoca- 
tive attacks  occur  after  the  remissions,  being  more  severe  than 
before.  There  is  now  a  fresh  exudation  occurring,  or  a  spasm 
of  the  glottis,  or  of  the  laryngeal  muscles,  which  has  given  rise 
to  it,  and  the  dyspnea  is  increased  through  the  special  influences 
which  are  at  work,  and  instead  of  the  remissions,  we  have  a 
disposition  to  pass  into  the  stage  of  asphyxia,  which  is  followed 
by  a  fatal  termination  of  the  case. 

"  Complications. — The  most  frequent  complication  is  bronchial 
catarrh,  but  the  diagnosis  of  its  degree  is  exceedingly  difificult. 
It  has  been  found  that  the  sibilant  and  sonorous  rales,  together 
with  the  pronounced  mucous  sounds,  disappear  immediately 
after  the  performance  of  tracheotomy,  indicating  that  the  con- 
gestion was  simply  a  temporary  one,  due  to  the  dyspnea.  In 
yet  other  cases,  after  a  free  entrance  of  air  to  the  lungs  has 
been  effected,  the  rales  still  continue  as  a  very  prominent  fea- 
ture. In  such  cases  a  coincident  bronchitis  has  arisen  from 
extension  of  the  inflammatory  process,  and  we  may  assume 
the  existence  of  fibrinous  exudation  in  various  portions  of  the 
bronchi  and  bronchioles. 


ACUTE  MEMBRANOUS  LARTNGITIS.  545 

**The  explanation  of  Niemeyer  (Ziemssen,  vol.  IV,  p.  251) 
seems  hardly  necessary.  His  view  is  that  the  pulmonary  alve- 
oli enlarge,  when  laryngeal  stenosis  has  obtained,  without  the 
entrance  of  a  suflficient  quantity  of  air,  thus  resulting  in  the 
rarefaction  of  the  air  contained  in  the  bronchi  and  alveoli.  This 
rarefied  air  acts  upon  the  bronchial  mucous  membrane  and 
upon  the  walls  of  the  alveoli,  just  as  cupping  does  upon  the 
skin,  the  result  being  congestion  and  increased  exudation  from 
the  blood-vessels  as  the  result  of  the  diminished  pressure  upon 
the  walls  of  the  vessels.  To  our  mind,  the  extension  of  the 
inflammatory  process,  as  in  other  forms  of  catarrh,  seems  to 
be  all  the  explanation  required.  Pneumonia  occurs  less  fre- 
quently as  a  sequence  of  croup ;  when  it  exists,  it  may  occur 
in  the  lobular  form,  not  so  often  as  a  lobar  pneumonia. 

"Atelectasis  may  occur  as  a  result  of  the  asphyxiated  stage 
of  croup.  The  portions  of  the  lung  involved  are  usually  the 
lower  and  posterior  parts.  Before  death,  their  presence  cannot 
be  recognized  readily  by  physical  examination,  unless  they 
should  involve  a  large  portion  of  the  lung,  which  is  not  usual. 
The  less  frequent  complications  are  pulmonary  apoplexy  and 
gangrene  of  the  lung.  It  is  doubtful  if  the  latter  ever  obtains 
in  a  case  of  true  croup  ;  the  instances  which  have  been  noticed 
are  undoubtedly  the  result  of  diphtheritic  laryngitis. 

'*  Course  and  Termination. — Croup  ordinarily  runs  its  course 
in  from  five  to  ten  days.  "  The  severest  cases  of  the  fulminant 
variety  may  terminate  fatally  in  from  twenty-four  to  forty-eight 
hours.  The  full  duration  is  from  four  to  six  days.  Instances 
are  on  record  in  which  the  exudation  of  false  membrane  on 
the  mucous  surface  of  the  larynx  and  bronchi  continued  for 
several  weeks. 

"  Pathology. — In  the  first  stage  of  the  disease,  the  main  feature 
is  an  intense  hyperemia  with  its  ordinary  accompaniments.  The 
mucous  surface  of  the  larynx  is  a  bright-red  color,  and  is  con- 
siderably swollen  and  puffy.  The  exudate  varies  from  a  very 
thin  pellicle,  to  a  thick,  firm,  tenacious  false  membrane,  which 
may  entirely  block  up  the  larynx.  Its  color  is  a  yellowish- 
white,  sometimes  brown  or  gray  ;  it  may  be  blackened  from  ex- 
travasation of  blood  ;  the  transudation  of  blood  may  be  sufifi- 
ciently  extensive  to  render  it,  in  some  instances,  blood-streaked, 
or  dotted  with  small  clots.  The  exudate  is  but  loosely  adher- 
ent to  the  mucous  surface,  and  may  be  readily  detached  ;  in 
other  instances  its  attachment  to  the  mucous  surface  is  much 
more  firm.  It,  however,  has  not  the  tendency  of  the  diphthe- 
ritic exudate  to  extend  into  the  mucous  tissue,  involving  the 
mucous  and  submucous  structures. 

"  While,  as  we  have  already  said,  this  anatomical  difference 
D.  C  — 35 


546  THE  DISEASES  OF  CHILDREN. 

does  not  warrant  us  in  assuming  its  non-identity  with  diph- 
theria, it  is,  notwithstanding,  a  decidedly  important  link  in  the 
chain  of  evidence.  The  disposition  of  the  exudate  is  to  extend 
downwards  rather  than  upwards.  The  early  writers  divided 
croup  into  the  ascending  and  descending,  and  it  is  admitted 
that  the  tendency  is  manifestly  downwards. 

"  It  is  easy  to  understand  how  quickly  the  dypsnea  may  be 
increased  by  the  presence  of  the  exudation  in  the  bronchioles  ; 
even  if  the  amount  of  membrane  in  the  larynx  should  not  be  ex- 
tensive, the  cutting  off  the  entrance  of  air  to  the  alveoli,  by 
the  filling  up  of  the  bronchioles,  adds  promptly  and  effectively 
to  the  amount  of  dypsnea. 

"  The  vocal  cords  are  especially  prone  to  be  the  seat  of  the 
exudate.  A  moderate  amount  of  exudation  at  this  point, 
therefore,  the  subglottic  space  being  quite  free,  may  induce 
dangerous  asphyxia.  The  inner  surface  of  the  glottis  is  gener- 
ally also  involved  to  a  marked  extent.  The  tendency  of  the 
membrane  is  to  reform,  which  constitutes  one  of  the  discourag- 
ing and  dangerous  features  of  croup.  After  the  first  exfoli- 
ation of  the  membrane  in  flakes  or  threads,  or  masses  of  consid- 
erable size,  a  second  formation  occurs,  and  even  a  third.  How 
much  this  reformation  is  influenced  by  the  active  methods  of 
treatment,  locally  and  internally,  which  have  been  in  use,  is  yet 
difficult  to  determine. 

"  Microscopically,  the  exudation  is  found  to  be  made  up  of 
amorphous,  or  fibrillated  fibrin,  with  numerous  young  cells. 
Chemically,  it  is  shown  to  be  coagulated  fibrin,  soluble  in  al- 
kalies, and  particularly  in  lime-water. 

"  Diagnosis. — The  early  diagnosis  is  attended  with  difficulty. 
It  is  impossible  to  designate  true  croup  from  a  severe  case  of 
infantile  laryngitis,  or  false  croup,  until  the  exudation  has  un- 
mistakably appeared. 

"  The  difficulty  of  laryngoscopic  examination  in  children  is 
much  to  be  deplored,  for  if  a  view  of  the  larynx  could  be  ob- 
tained, an  early  and  positive  diagnosis  could  be  made.  Some 
of  the  cases  of  infantile  laryngitis,  as  in  the  one  already  referred 
to,  unfortunately  present  symptoms  which  render  their  differ- 
entiation from  true  croup  entirely  impossible.  On  the  second 
or  third  day  it  is  usually  possible  to  make  the  diagnosis  with 
accuracy,  if  careful  attention  is  paid  to  all  the  points.  One 
prominent  diagnostic  feature  is,  that  in  pseudo-croup  there  is  a 
much  greater  amenability  to  treatment  ;  there  is  not,  usually, 
so  strong  a  disposition  to  the  continuance  of  the  dypsnea  ;  it 
is  not  so  intense  nor  so  prominent.  In  false  croup  the  febrile 
movement  is  more  readily  controlled  ;  there  is  not  as  much 
hoarseness,  the  voice  is  not  as  frequently  lost,  nor  as  harsh  and 


ACUTE  MEMBRA  NO  US  LA  R  TNGITIS.  547 

rough.  Instead,  also,  of  tending  to  grow  hoarse  on  the  sec- 
ond or  third  day,  false  croup  is  ameliorated,  as  a  rule,  on  the 
second  night,  and  largely  disappears  upon  the  third.  The 
steady  progress  of  the  symptoms  from  the  first  should 
incline  us  to  apprehend  that  we  are  dealing  with  a  case  of  true 
croup. 

"  In  false  croup,  the  suffocative  attacks  do  not  occur  so  often, 
and  are  not  so  severe.  Parents,  and  even  physicians,  often  say 
that  they  have  had  children  affected  with  several  attacks  of  true 
croup ;  undoubtedly,  such  cases  are  those  of  severe  infantile 
laryngitis  without  any  exudation  whatever. 

"  It  may  be  mistaken  for  edema  of  the  glottis,  but  if  we  note 
carefully  the  history  of  the  case,  and  make  a  thorough  exami- 
nation, we  can  usually  settle  the  diagnosis.  Palpation,  which 
can  always  be  employed  before  the  case  has  progressed  far, 
will  put  us  on  the  right  track.  Spasm  of  the  glottis  is  more 
likely  to  be  confounded  with  this  affection,  but  its  convulsive 
nature  enables  us  to  distinguish  it.  Between  the  paroxysms  the 
child  is  perfectly  well ;  there  are  no  croupy  sounds,  no  hoarse- 
ness, no  stridor.  In  most  instances,  there  is  not  in  croup,  or 
at  least  only  very  occasionally,  a  tendency  to  spasm  of  a  carpo- 
pedal  form. 

"  Foreign  bodies  in  the  larynx  induce  symptoms  which  greatly 
resemble  croup.  The  child  is  taken  with  sudden  stridor  and 
dyspnea,  together  with  hoarseness  and  a  sense  of  obstruction  to 
respiration.  In  these  cases,  also,  the  history  usually  enables  us 
to  make  a  diagnosis.  We  have  already  given  the  points  of  di- 
agnosis between  laryngeal  diphtheritis  and  true  croup. 

"  Injuries  of  the  larynx  and  morbid  growths  of  the  larynx 
give  rise  to  croupy  symptoms,  but  the  diagnosis  of  these  affec- 
tions is  generally  rendered  easy  by  examination. 

"  Prognosis. — True  croup  is  an  exceedingly  fatal  disease.  The 
fatality  ranges  from  23  to  75  per  cent.  There  are  some  cases 
which  seem  to  resist,  from  the  start,  all  treatment,  however 
carefully  and  judiciously  applied.  With  the  evidence  which 
we  have  of  its  deadliness,  the  statement  of  Cohen,  since  he  has 
used  the  treatment  of  inhalations  of  steam  in  a  hot  room,  should 
be  carefully  noted. 

"  We  cannot  believe  that  healthy,  robust  children  succumb  as 
readily  to  the  disease  as  do  the  feeble.  Our  view  is  emphatic- 
ally that  it  is  a  disease  of  scrofulous  children  ;  that  the  strong 
and  robust  bear  the  brunt  of  it  much  more  readily,  and  afford 
more  hope  of  relief  from  treatment.  A  careful  analysis  of 
cases  treated  will  show  that  the  children  attacked,  who  were, 
before,  subject  to  enlarged  glands  and  other  manifestations  of 
scrofulosis,  succumb  almost  surely." 


548  THE  DISEASES  OF  CHILDREN. 

(It  is  very  rare  to  see  a  fatal  case  of  croup  among  children 
who  have  been  accustomed  to  plenty  of  outdoor  exercise  and 
who  are  free  from  scrofulous  and  syphilitic  taint.  The  children 
of  robust  constitution,  even  though  subject  to  privation  and 
neglect,  are  not  the  favorite  victims.  It  prefers  the  weaklings, 
the  hot-house  plants,  that  are  given  every  care  and  surrounded 
with  every  luxury ;  overfed,  overclothed  and  kept  indoors 
much  of  the  time  for  fear  of  "  taking  cold."  It  is  always  the 
delicate,  sensitive,  pale-faced  child  who  knows  nothing  about 
"  roughing  it,"  that  falls  an  easy  victim  to  croup.) 

"  The  tendency  to  a  fatal  termination  is  increased  by  the  oc- 
currence of  complication.  If  we  have  bronchitis  or  pneumonia 
supervening,  the  danger  is  greatly  intensified.  Even  when  the 
membrane  is  confined  largely  to  the  larynx,  there  is  but  a 
slight  prospect  of  recovery,  though,  of  course,  it  is  better  than 
if  the  membrane  extends  above  or  below.  There  is  little  hope 
when  we  find  severe  and  continued  dyspnea  with  suffocative 
attacks  occurring  often,  febrile  movement  high,  and  the  stenosis 
marked,  and  stupor  present,  in  a  greater  or  less  degree,  with  an 
intermittent  pulse. 

"  During  the  stage  of  asphyxia,  it  is  generally  the  course  for 
three  paroxysms  of  collapse  to  occur.  This  clinical  feature 
gives  us  an  indication  for  tracheotomy,  which  should  be 
promptly  employed  after  the  first  attack  of  collapse.  The  pa- 
tient will  rally  from  this  under  the  use  of  a  small  amount  of 
stimulant,  and  then  the  operation  can  be  performed. 

"  Exudation. — If  there  is  any  exudation  on  the  pharynx, 
which  my  experience  demonstrates  to  be  somewhat  rare,  the 
true  nature  of  the  disease  is  certain  ;  but  the  exudation  is  usu- 
ally out  of  sight,  and  tends  to  extend  downwards,  and  to  in- 
volve the  trachea  and  bronchi,  even  to  the  bronchioles,  and  all 
know  the  difficulty  of  laryngoscopic  inspection  in  children. 
With  a  little  tact,  the  use  of  the  mirror  in  the  throat  with  a 
a  strong  direct  light  may  be  effected  in  some  instances  ;  such  an 
examination  will  readily  show  the  exudation.  If  not  seen,  its 
presence  may  be  assumed  from  the  history  and  symptoms,  and, 
later,  we  have  the  expulsion  of  the  membrane  in  flakes  or  casts. 
The  larynx,  trachea,  and  bronchioles  have  all  been  implicated, 
as  post-mortem  examinations  have  shown.  Sometimes  only 
inspissated  mucus  is  thrown  off  for  awhile.  If  inspiration  and 
expiration  are  equally  affected,  we  may  assume  the  presence  of 
adventitious  membrane ;  if,  however,  inspiration  is  difficult  and 
expiration  easy,  we  have  merely  a  paralytic  state  of  the  glottis." 

Treatment. — The  value  of  moist  air  in  cases  of  croup  is  rec- 
ognized by  all  schools  of  practice.  This  can  best  be  secured 
by  using  a  steam  atomizer,  or  a  kettle  of  water  kept  boiling  by 


ACUTE  MEMBRANOUS  LARTNGITIS.  549 

means  of  a  spirit  lamp,  and  limit  the  breathing-space  of  the 
patient  by  means  of  an  improvised  tent,  erected  over  the  whole, 
or  upper  portion  of  the  bed.  The  vapor  may  be  medicated 
with  comp.  tr.  of  benzoin,  or  carbolic  acid,  or  still  better,  per- 
haps, with  acetic  acid. 

Dr.  S.  J.  Bunstead,  in  the  North  American  Practitioner 
speaks  very  highly  of  vinegar,  as  a  therapeutic  resource,  both 
in  catarrhal  and  membranous  croup.  He  uses  it  in  the  form  of 
vapor,  pouring  the  liquid  into  a  bread-pan,  and  then  putting 
into  it  bricks  or  flatirons  heated  in  the  stove.  When  introduced 
under  the  tent,  the  air  soon  becomes  saturated  with  acetic  va- 
por. The  inhalation  of  the  vapor  from  slacking  lime,  has,  it  is 
claimed,  saved  the  lives  of  many  patients. 

The  late  Dr.  Nicho.  Francis  Cooke  never  wearied  of  telling  of 
a  case  of  croup  which  occurred  at  one  of  the  principal  hotels  in 
this  city,  and  in  the  course  of  which  thirty  barrels  of  lime  were 
used  in  this  way,  with  successful  results.  Dr.  Solis  Cohen,  of 
Philadelphia,  claims  to  have  saved  every  case  of  membranous 
laryngitis  since  he  adopted  the  method  of  inhalations  of  steam 
in  a  heated  room.  His  plan  is  to  place  the  patient,  after  it  is 
manifest  there  is  an  exudation,  in  a  closed  room  heated  to  a 
temperature  of  80°  Fahr.,  which  should  be  constantly  main- 
tained without  intermission  until  the  child  is  out  of  danger. 
The  room  is  then  surcharged  with  moisture  by  hanging  pieces 
of  cloth,  or  towels,  wet  with  hot  water,  about  the  room.  The 
water  is  placed  upon  the  stove  or  grate,  and  by  the  placing  of 
hot  flatirons  in  pans  of  water,  sufificient  steam  is  generated  to 
produce  a  considerable  degree  of  moisture.  It  is  claimed  that 
by  this  process  the  exudate  is  softened  and  finally  exfoliated. 

During  last  summer,  being  called  out  of  town  for  a  few  days, 
I  was  compelled  to  leave  a  child  suffering  from  membranous 
croup  with  my  friend,  Dr.  L.  C.  Grosvenor.  The  child  had 
been  ill  for  several  days,  and  on  the  day  I  left  the  city  was 
voiceless,  and  at  times  cyanotic.  The  respirations  were  very 
labored,  and  it  seemed  as  if  intubation  would  soon  become 
necessary  to  prevent  suffocation.  On  my  return  I  found, 
somewhat  to  my  surprise,  that  the  child  was  making  a  good 
recovery,  and  no  operative  procedure  had  been  necessary.  I 
was  informed  by  Prof.  G.  that  on  his  first  visit  to  the  case 
he  had  instructed  the  parents  to  spray  the  child's  throat  with 
peroxide  of  hydrogen,  which  produced  its  characteristic  effects 
when  pus  is  present,  and  after  a  few  hours,  a  complete  cast  of 
the  larynx  with  tracheal  branches  was  coughed  up,  with  an  im- 
mediate relief  of  all  serious  symptoms. 

In  this  case  there  was  at  no  time  any  visible  exudation  in  the 
pharynx,  or  on  the  tonsils.     The  sick  child  was  two-and-a-half 


550  THE  DISEASES  OF  CHILDREN. 

years  old,  and  the  family  consisted,  besides  the  parents,  of  two 
other  children,  one  younger,  and  one  older  than  the  sick  one, 
who  were  necessarily  constantly  in  the  sick  room,  as  the  family 
occupied  a  flat  of  but  three  rooms.  Notwithstanding  these 
other  children  lived  in  the  same  rooms,  breathed  the  same  air, 
and  were  constantly  about  the  patient,  they  remained  well. 
This  fact  was  to  my  mind  conclusive  proof  that  there  was  noth- 
ing diphtheritic  about  the  attack.  It  was  a  case  of  simple, 
non-specific  membranous  laryngitis.  I  can  only  explain  the 
action  of  the  peroxide  on  the  supposition  that  there  must  have 
been  a  secretion  of  pus  behind  and  beneath  the  membrane 
which  was  decomposed  by  the  inhalation,  with  the  effect  of 
loosening  and  throwing  off  of  the  deposit  in  the  manner 
described. 

Dr.  A.  G.  Beebe,  of  this  city,  whose  conservatism  of  state- 
ment is  well  known,  says  that  for  twenty  years  past  he  has 
used  with  uninterrupted  success,  in  the  treatment  of  all  forms  of 
non-diphtheritic  croup,  a  preparation  of  iodide  of  lime,  as  pre- 
pared by  Billings,  Clapp  &  Co.,  of  Boston.  It  is  a  nearly  black 
powder,  and  is  given  in  doses  of  one-fourth  to  one-half  grain  of 
the  crude  drug  at  intervals  of  an  hour,  or  if  the  symptoms  are 
urgent,  as  often  as  every  fifteen  or  thirty  minutes  for  the  first 
few  doses.  It  should  be  continued  until  the  dry,  croupy  cough 
gives  place  to  a  moist  or  catarrhal  one,  and  until  all  danger  of 
recurrence  during  the  night  has  passed.  It  may  be  conveniently 
given  mixed  (not  triturated)  with  sugar  of  milk,  so  as  to  make 
a  convenient-sized  dose,  or  it  may  be  put  into  water ;  but  as  it 
is  a  very  unstable  preparation,  it  should  be  exposed  to  light 
and  air  as  little  as  practicable. 

The  remedies  which  are  especially  homeopathic  to  mem- 
branous croup,  are : 

Aconite. — Useful  especially  in  the  early  stages,  where  it  may 
limit  the  extent  and  intensity  of  the  inflammation,  and  thus 
abort  the  formation  of  membrane  or  lessen  its  amount. 

Arsenicum. — Edema  of  the  glottis,  in  pale  and  debilitated 
children  ;  great  restlessness  ;  scanty  urine  ;  great  dypsnea. 

Bromin. — Cough  dry  and  wheezy  ;  dyspnea  marked  ;  expec- 
toration scanty;  aggravation  in  spite  of  aconite  ;  hoarseness  tend- 
ing to  aphonia. 

Hepar  Sidph. — Feeling  as  if  there  were  a  foreign  body  in  the 
larynx ;  stitching  pains  from  ear  to  ear ;  febrile  movement 
marked  ;  inspiration  difficult,  expiration  easy  ;  loose  cough,  but 
no  expectoration  ;  rattling  of  moist  mucus  ;  aggravation  after 
midnight  or  towards  morning. 

Kali  Bichromicum. — Gradual  and  insidious  onset ;  at  first 
only  slight  difficulty  of  breathing,  which  increases  as  the  dis- 


ACUTE  MEMBRANOUS  LARYNGITIS.  551 

ease  progresses  ;  hoarse  voice,  with  constant  paroxysmal  cough  ; 
tonsils  and  pharynx  red  and  swollen  ;  tough,  stringy  mucus  in 
mouth ;  breath  offensive ;  especially  adapted  to  diphtheritic 
cases,  in  which  it  covers  better  than  any  other  remedy  the  to- 
tality of  the  symptoms.  This  remedy  offers  more  hope  than 
any  other  of  softening  the  membrane  and  effecting  its  expul- 
sion. The  more  the  case  resembles  one  of  non-malignant  diph- 
theria, the  more  clearly  is  it  indicated,  and  is  well  adapted  to 
those  cases  where  the  diphtheria  has  extended  into  the  larynx 
and  trachea. 

Sanguinaria. — Sensation  of  swelling  in  the  larynx,  with  ex- 
pectoration of  thick  mucus  ;  aphonia ;  tormenting,  exhaustive 
cough  ;  severe  cough,  without  expectoration  ;  dryness  of  throat, 
with  feeling  of  fullness  of  larynx,  as  if  swollen. 

See  also  belladonna^  causticum,  lactic  acid,  lycopodium  and 
spongia. 


CHAPTER    VII. 

PNEUMONITIS  (inflammation  OF  THE  LUNGS). 

Synonyms. — First,  Croupous  Pneumonia  ;  Lung  Fever  ;  Lobar 
Pneumonia.  Second,  Lobular  Pneumonia  ;  Catarrhal  Pneumo- 
nia ;  Broncho-Pneumonia. 

It  is  rather  to  satisfy  the  demands  of  jnodern  pathology  than 
to  subserve  any  material  end,  that  the  practice  is  here  followed 
of  dividing  the  pneumonias  into  lobar  or  croupous,  and  lob- 
ular or  catarrhal  pneumonia.  While  post-mortem  examination 
of  the  lungs  may  reveal  a  marked  distinction  between  the  two 
varieties,  the  clinical  differences  observed  during  life  are  so 
vague  and  indefinite  as  to  result  rather  in  confusion  than  prac- 
tical help.  While  acute  lobar  pneumonia  is  probably  quite 
common  in  childhood,  it  does  not  usually  run  the  typical 
course  which  it  does  when  adults  are  affected.  It  partakes 
more  often  of  the  symptoms  of  the  catarrhal  form,  whether  an  en- 
tire lobe  is  involved  or  only  certain  portions  or  lobules,  and  the 
diagnostician  must  be  very  expert  who  can  say  positively  in  a 
given  case  which  he  has  to  deal  with.*  Goodhart,  in  his  American 
edition  of  "  Diseases  of  Children,"  edited  by  Starr,  says  :  "Acute 
pneumonia,  be  it  clinical,  lobar,  or  lobular,  seems  to  me  to  pre- 
sent such  appearances  in  every  case  as  make  any  distinction 
between  the  two  forms,  save  one  of  degree,  a  very  difficult 
matter."  Nor  are  we  aided  in  a  practical  way  by  the  dictum  of 
modern  pathology,  that  lobar  pneumonia  is  always  "  a  specific, 
infectious,  self-limited  disease,  giving  rise  to  definite  temporary 
pulmonary  lesions  ;"  *and  broncho-pneumonia  is  an  "  acute  in- 
flammation of  the  bronchial  lining  membrane,  which,  by  direct 
extension  and  mechanical  phenomena  incidental  to  the  disease, 
involves  the  connective  tissue,  bronchioles  and  air  cells."t  It 
is  quite  probable  that  filthy  and  illy-ventilated  homes,  crowded 
tenements  and  damp  basements  may  give  rise  to  lobar  pneu- 
monia, and  to  that  extent  and  in  that  sense,  it  is  undoubtedly 
"  infectious,"  but  the  same  surroundings  precisely  may  give 
rise,  also,  under  certain  other  favoring  conditions,  to  bronchitis, 
asthma,  laryngitis,  or  to  lobular  pneumonia. 


*  Francis  Minot,  in  Keating^s  Cyclopedia. 
+  F.  Gordon  Morrill,  idem.' 

(552) 


PNE  UM  ONI  T/S.  553 

The  diagnosis  between  bronchitis  and  pneumonia  in  the  adult 
is  oftentimes  exceedingly  difficult,  and  with  children  impossible. 
The  one  is  so  intimately  associated  with  the  other  that  it  re- 
quires a  keen  perception  to  discover  where  one  leaves  off  and 
the  other  begins.  There  are  those  of  the  highest  standing  in 
the  profession,  and  who  are  credited  with  having  a  verj'  extended 
experience  in  pulmonary  diseases,  who  fail  to  make  any  distinc- 
tion between  capillary  bronchitis  and  certain  forms  of  broncho- 
pneumonia. The  distinction,  when  made,  is  of  no  practical 
value,  either  from  a  diagnostic,  prognostic  or  therapeutic  point 
of  view. 

The  vital  function  of  the  lungs  is  to  aerate  and  depurate  the 
blood,  and  any  impairment  of  this  function  is  attended  with 
consequences  which  are  disastrous  in  direct  proportion  to  the 
amount  of  impairment.  If  a  bronchiole  is  plugged  up  so  as  to 
exclude  the  air  from  the  pulmonary  vesicle  to  which  it  leads, 
it  makes  no  practical  difference  whether  the  plug  is  of  mucus 
or  fibrin  ;  and  the  same  is  true  of  the  vesicle  itself.  In  either 
case  the  function  of  the  part  involved,  be  it  bronchial  or  vesical, 
is  impaired,  and  the  act  of  respiration  is  to  this  extent  curtailed. 

The  etiology  of  the  two  varieties  of  pneumonia  will  only 
show  "a  distinction  without  a  difference."  While  lobar  and 
lobular  pneumonia  exhibit  but  trifling  differences  in  their  caus- 
ation and  symptoms,  their  morbid  anatomy  does  show  marked 
peculiarities,  which  seem  to  distinguish  them  one  from  the 
other,  as  we  shall  proceed  to  explain.  In  croupous  pneumonia, 
the  pathological  anatomy  does  not  differ  materially  from  that 
of  the  adult. 

There  is,  first,  hyperemia  or  congestion  ;  next,  solidification  or 
hepatization,  and  then  softening  or  liquefaction. 

Suppuration  and  gangrene  of  the  lung,  which  are  often  seen 
in  the  adult,  are  very  rare  in  the  pneumonias  of  infancy.  The 
three  principal  stages  are,  as  a  rule,  not  clearly  defined,  and  it 
is  no  unusual  thing  to  find  them  all  existing  at  the  same  time 
in  the  affected  organ. 

The  first  stage,  or  that  of  engorgement,  is  characterized  by  a 
darker  color  of  the  lung  substance  than  is  natural,  and  to  the 
touch  it  conveys  a  doughy  feeling,  as  if  the  lung  was  edema- 
tous. When  cut,  the  lung  tissue  emits  a  frothy,  bloody  serum  ; 
the  frothy  appearance  being  due  to  the  admixture  of  air  bub- 
bles with  the  lighter  or  darker  sanguinolent  fluid.  A  portion 
of  lung  in  this  stage,  if  thrown  into  water,  has  sufficient  air  in 
it  to  keep  it  from  sinking,  and  if  lightly  squeezed  and  washed, 
it  can  be  restored  to  nearly  its  normal  condition.  The  less  air 
and  more  fluid  found  in  the  lung,  the  greater  or  more  intense 
has  been  the  inflammation.     When  the  stage  of  hepatization  is 


554  THE  DISEASES  OF  CHILDREN. 

reached,  the  tissues  are  of  a  brick-red  color;  there  is  a  greater 
degree  of  solidity,  and  the  affected  portions  of  the  lung  are  fria- 
ble, resembling  the  liver,  from  which  resemblance  this  stage 
derives  its  name.  The  hepatized  lung  is  swollen,  and  often 
bears  the  imprint  of  the  ribs  on  its  surface.  Slight  pressure 
causes  a  very  little  bloody  fluid  to  exude  from  the  cut  surface 
without  a  trace  of  air  bubbles. 

A  section  of  the  lung  has  a  streaked  or  speckled  appearance, 
which  is  due  to  the  bronchi  and  their  vessels,  which  have  es- 
caped the  inflammation,  and  are,  therefore,  lighter  colored. 
There  are  multitudes  of  minute  elevations  projecting  from  the 
cut  surface,  which  are  the  alveoli  distended  with  a  viscid  exu- 
dation. Under  the  microscope,  this  exudation  is  seen  to  be 
composed  of  a  granular  form  of  albuminoid  matter,  with  red  or 
white  blood  corpuscles,  and  an  abundance  of  new  cell-formations 
in  the  air  vesicles.  Sometimes  fatty  globules  are  seen,  which 
are  probably  due  to  the  fatty  metamorphosis,  which  takes  place 
prior  to  absorption  of  those  products, 

A  hepatized  lung  will  often  be  found  to  have  increased  to  ten 
times  its  normal  weight. 

The  morbid  appearances  of  the  third  stage,  or,  as  it  some- 
times is  called,  the  stage  oi  gray  hepatization^  are  purely  hypo- 
thetical. It  is  the  stage  of  resolution  ;  of  absorption.  Doubt- 
less it  retains  many  of  the  characteristics  of  the  preceding  stage. 
The  color  changes  from  dusky-red  to  granite-gray.  It  is  still 
solid,  granular  and  lacking  air,  and  still  sinks  if  thrown  into 
water.  But  gradually  the  engorgement  and  infiltration 
undergo  liquefaction  and  absorption.  The  fatty  metamor- 
phosis before  alluded  to  doubtless  assists  in  this  process  of 
resolution.  Children  do  not  expectorate,  and  during  conva- 
lescence from  pneumonia  are  generally  troubled  but  little  from 
mucus  in  the  tubes.  Under  unfavorable  conditions,  hepatiza- 
tion may  undergo  a  change  into  purulent  infiltration,  in  which 
case  recovery  is  possible,  but  often  long  delayed.  When  lim- 
ited in  extent,  it  may  become  surrounded  by  a  wall  of  connect- 
ive tissue,  and  gradually  be  eliminated  by  abscess  formation. 
The  pleura  corresponding  to  the  pulmonary  lesion  is  generally 
more  or  less  involved,  and  in  severe  cases,  there  is  the  usual 
accompaniment  of  exudation  of  plastic  lymph  or  serum. 

The  morbid  appearances  of  lobular  or  broncho-pneumonia 
differ  somewhat  from  those  just  described,  especially  when  oc- 
curring in  children.  There  is,  perhaps,  a  greater  dissemination 
of  the  morbid  changes.  The  bronchial  mucous  membrane  is 
more  involved,  and  pours  forth  an  abundant  secretion,  which 
naturally  finds  its  way  to  the  most  dependent  portion  of  the  lung, 
which    in    a   sick  child  is  posteriorly  ;    and  it  is  usually   the 


PNE  UMONI TIS.  555 

posterior  portion  of  the  lungs  that  is  affected  in  broncho- 
pneumonia. The  inflammatory  process  not  being  restricted,  as 
in  lobar  pneumonia,  spreads  irregularly  in  various  directions.  It 
invades  the  bronchioles  and  air-cells,  and  spreads  also  out- 
wardly to  the  bronchial  walls,  and  the  surrounding  connective 
tissue.  This  extension  of  the  inflammatory  process  and  its  re- 
sults may  be  rapid,  and  equivalent  to  a  simultaneous  invasion 
of  all  the  tissues  involved  ;  or  it  may  be  slow  and  gradual,  oc- 
cupying weeks  or  even  months.  The  manner  in  which  the  in- 
flammation may  spread  in  broncho-pneumonia  is  either  by  the 
migration  of  the  bronchial  secretion,  which  acts  as  an  irritant 
wherever  it  penetrates,  or  by  the  action  of  the  original  causes 
of  the  inflammation  affecting  different  centers  or  foci,  from 
which  large  portions  of  lung  are  involved  by  natural  extension 
along  the  mucous  surface. 

In  all  cases  of  average  duration  and  severity,  there  is  danger 
of  collapse  of  some  of  the  air-cells,  which  in  some  instances  is 
a  formidable  accident.  In  these  cases  the  walls  of  the  alveoli, 
not  being  distended  with  air,  come  into  apposition  and  remain 
so,  until  in  the  course  of  the  process  of  resolution  the  bronchi- 
oles are  free  and  open  to  the  ingress  of  the  inspired  air,  when, 
under  favoring  circumstances,  they  resume  again  their  normal 
size  and  function. 

From  this  it  will  be  seen  that  lobar  pneumonia  is,  patholog- 
ically, a  primary  affection,  affecting  the  parenchyma  of  the  lung, 
and  showing  but  little  tendency  to  involve  the  bronchioles  or 
the  air  vesicles  ;  while  lobular  or  broncho-pneumonia  is,  as  a  rule, 
a  secondary  affection,  involving  the  bronchioles  and  the  alveoli 
by  an  extension  of  inflammation  along  their  mucous  lining. 
Lobar  pneumonia  produces  solidification  of  pulmonary  tissue 
by  blood  stasis ;  lobular  pneumonia,  by  incarcerated  mucus, 
epithelium,  pus  or  other  products  of  inflammation  originating 
in  the  tubes  or  their  termini.  Lobar  pneumonia  may  be  asso- 
ciated with  bronchitis ;  lobular  pneumonia  is  always  so  asso- 
ciated. The  former  always  involves  a  whole  lobe  or  lobes,  or 
a  goodly  part  thereof,  while  the  latter  may  involve  but  small 
and  scattered  portions  of  a  lobe  or  lobes ;  the  one  runs  a  brief 
and  limited  course,  while  the  other,  by  migration  of  morbid 
secretions,  or  natural  extension  of  inflammation,  may  perpetu- 
ate itself  indefinitely. 

When  lobar  pneumonia  becomes  chronic,  it  is  because  of  a 
failure,  either  in  part  or  in  whole,  of  nature's  efforts  to  dispose 
of  the  products  of  inflammation  ;  but  lobular  pneumonia  par- 
takes of  the  characteristics  of  all  catarrhal  affections,  and  be- 
comes chronic  from  the  lowered  tone  of  the  tissue  involved, 
and  the  inability  of  the  patient  to  expel  the  catarrhal  products. 


556  THE  DISEASES  OF  CHILDREN. 

From  a  clinical  point  of  view,  it  is  plain  to  be  seen  how  im- 
possible it  is  to  distinguish  in  the  majority  of  cases  between  an 
inflammation  which  is  confined  to  the  bronchioles  or  their  ter- 
minal alveoli,  and  an  inflammation  just  outside  of  these  tissues. 
And  it  is  just  here  where  the  intelligent  homeopathic  physician 
need  suffer  no  confusion.  To  him  the  "  totality  of  the  symptoms 
constitutes  the  disease"  and  the  remedy  or  drug  which  best 
covers  this  "  totality  of  symptoms,"  is  the  one  sought  for  and 
prescribed  with  serene  confidence  in  its  curative  action. 

Clinical  History, — As  a  rule,  pneumonia  in  children  is  not 
attended  with  prodromal  symptoms.  The  chill  which  marks 
the  onset  of  the  disease  in  adults  is  generally  lacking.  If  pres- 
ent at  all,  it  is  an  ill-defined  chilliness  rather  than  a  rigor,  and 
of  short  duration.  The  early  symptoms  consist  of  cough,  pain 
in  the  side,  drowsiness,  loss  of  appetite,  and  perhaps  vomiting. 
Fever  quickly  follows,  with  flushed  face,  hot  skin,  restlessness, 
rapid  pulse  and  accelerated  breathing.  In  very  young  infants, 
convulsions  are  not  uncommon.  The  temperature  rapidly 
attains  a  height  of  103°,  or  even  105°,  and  falls  somewhat, 
ordinarily,  as  the  second  stage  of  the  disease  is  reached. 

The  disease  is  now  fully  developed,  and  the  physical  signs 
show  engorgement  of  certain  portions  of  the  lungs  correspond- 
ing to  the  parts  affected.  The  cough  is  more  or  less  frequent, 
and  if  the  pleura  is  much  involved,  is  attended  with  pain.  A 
deep  flush  is  noticeable  on  one  or  both  cheeks,  and  an  herpetic 
eruption  is  often  seen  on  the  lips. 

The  breathing  is  hurried  and  shallow,  and  the  nostrils  dilate 
with  each  inspiration.  The  temperature  is  lowest  in  the  morn- 
ing, the  thermometer  registering  102°  or  103°  Fahr.  It  rises 
towards  midday,  and  by  evening  may  reach  as  high  as  104°,  or 
even  106°,  in  severe  cases. 

In  broncho-pneumonia  the  temperature  is  subject  to  sudden 
variations.  Every  extension  of  inflammation  involving  any 
considerable  number  of  fresh  alveoli,  is  attended  by  a  rise  of 
fever.  From  this  cause,  the  temperature  may,  in  some  cases, 
be  higher  in  the  morning  than  it  is  in  the  evening,  or  at  mid- 
night. When  areas  of  considerable  size  collapse,  the  dyspnea 
increases,  the  temperature  diminishes,  and  the  cough  may  en- 
tirely cease.  This  is  of  bad  omen.  The  countenance  soon 
becomes  livid,  the  pulse  small  and  weak,  and  unless  a  radical 
change  takes  place  for  the  better,  death  ensues  in  the  course  of 
twenty-four  or  thirty-six  hours. 

When  the  second  stage  has  lasted  for  a  period  of  from  three 
to  six  days,  in  case  a  favorable  change  takes  place,  the  tempera- 
ture falls  suddenly,  the  breathing  becomes  easier  and  a  profuse 
sweat  marks  the  crisis  of  the  disease.     This  does  not  occur,. 


PNE  UMONI TIS.  557 

however,  until  the  process  set  up  by  the  inflammation  is  com- 
plete. In  connection  with  the  sweat,  the  patient  usually  experi- 
ences an  inordinate  flow  of  urine,  or  a  diarrhea. 

Vomiting  is  present  to  a  greater  or  less  extent  in  nearly  one- 
half  of  all  cases.  When  broncho-pneumonia  complicates  measles, 
it  generally  occurs  during  the  eruptive  stage  of  that  disease,  or 
at  least  begins  before  the  rash  has  entirely  faded.  In  such 
cases,  it  runs  a  brief  course,  and  death  or  convalescence  is 
reached  within  a  week. 

The  duration  of  the  different  stages  may  be  generalized  as 
follows:  The  stage  of  engorgement  lasts  usually  but  a  few 
hours  ;  that  of  red  hepatization  takes  twenty-four  or  forty-eight 
hours  for  the  exudative  process  to  complete  itself,  and  two  to 
four  days  for  solidification  to  continue  before  absorption  begins; 
the  stage  of  gray  hepatization  is  very  apt  to  be  terminated 
within  a  few  days  by  death.  In  mild  cases,  the  first  stage  may 
not  progress  to  the  development  of  inflammatory  products,  but" 
may  simply  end  by  resolution.  More  commonly  it  goes  on  to 
hepatization,  and  then,  instead  of  ending  in  purulent  infiltration, 
it  gives  way  to  the  reparative  process  of  resolution  or  absorp- 
tion. This  stage  of  resolution  lasts  for  from  three  to  five  days 
and  may  last  for  weeks.  In  cases  in  which  disease  does  not 
progress  favorably,  the  addition  of  threatening  symptoms  usu- 
ally takes  place  about  the  third  or  fourth  day.  The  tempera- 
ture rises,  the  pulse  becomes  smaller  and  more  frequent,  and 
there  is  a  marked  increase  in  the  difficulty  of  breathing.  The 
patient  cannot  lie  down,  but  must  be  propped  up  with  pillows, 
while  the  act  of  respiration  is  performed  laboriously.  When 
cases  are  prolonged  beyond  five  or  six  days,  it  has  long  been 
noticed  that  there  is  a  decided  tendency  to  ameliorate  on  cer- 
tain other  days.  These  critical  days,  as  they  are  called,  are 
commonly  the  seventh,  eleventh,  fourteenth  and  twentieth. 
There  is  great  tendency  in  pneumonia  to  relapse,  and  relapses 
always  find  their  subject  more  or  less  exhausted  by  the  previ- 
ous attack  and  less  able  to  withstand  the  renewed  shock  of  the 
inflammation. 

Physical  Signs  and  Symptoms. — The  diagnosis  of  pneumonia 
in  adults  is  greatly  facilitated  by  our  ability  to  examine  the 
sputa,  and  by  the  light  which  is  shed  upon  obscure  cases  by 
auscultation  and  percussion.  In  infancy  and  early  childhood, 
we  do  not  receive  any  aid  from  the  sputum,  for  the  reason  that 
none  of  it  is  expectorated.  What  little  is  raised  to  the  fauces 
is  immediately  swallowed,  and  passes  into  the  stomach,  there 
to  produce  disorders  in  the  shape  of  gastric  inflammation  or 
more  often  diarrhea.  In  infancy  the  strength  is  not  sufficient 
to  dislodge  and  dispose  of  the  products  of  pulmonary  disease, 


558  THE  DISEASES  OF  CHILDREN. 

and  this  is  one  of  the  reasons  why  pneumonia  is  so  perilous  at 
this  period  of  life.  Owing  to  the  limited  areas  affected  in  many 
cases  of  lobar  pneumonia,  and  its  position  in  the  center  of  a 
lobe  with  healthy  tissue  all  around  it,  it  is  sometimes  late  in 
the  progress  of  a  case  before  auscultation  and  percussion  yield 
any  satisfactory  results.  The  difficulty  of  employing  these  aids 
to  diagnosis,  which  are  so  valuable  in  treating  adults,  is  en- 
hanced by  the  willfulness  or  fright  of  the  child,  which  refuses  to 
be  pacified  long  enough  for  anything  like  a  careful  and  critical 
examination.  In  cases  where  auscultation  can  be  made  availa- 
ble, it  points  to  more  or  less  embarrassment  in  the  atmospheric 
ingress  and  egress  into  the  minute  bronchial  ramifications. 
This  hindrance  to  respiration  is  at  times  the  result  of  great 
engorgement  and  stasis  of  blood,  and  again  it  is  due  to  large 
secretory  accumulations,  or  to  simple  collapse  of  the  air-cells. 
During  the  first  stage,  or  stage  of  engorgement,  it  is  not  com- 
mon to  hear  the  fine  crepitant  rale  which  accompanies  this 
condition  in  the  adult.  A  moist  rale  is  heard  more  frequently. 
During  the  first  twelve  hours,  auscultation  will  give  ordinarily 
the  hissing  or  sibilant  ronchus,  from  dryness  of  the  mucous 
membrane  from  the  inflammation ;  but  this  is  soon  replaced  by 
a  moist  ronchus,  caused  by  the  excessive  mucus  secretion 
which  is  being  poured  into  the  tubes.  Percussion  is  likely  to 
yield  better  results  than  auscultation.  A  dull  or  flat  sound  is 
elicited  over  the  affected  areas,  and  pleuritic  complication  will 
be  shown  by  wincing  or  other  evidence  of  pain  when  certain 
portions  of  the  chest  are  percussed,  which  will  be  confirmed 
by  a  careful  comparison  of  the  two  sides.  During  the  stage  of 
hepatization,  true  bronchial  respiration  can  be  clearly  heard, 
after  which  it  is  replaced  by  moist  crepitation.  For  some  day» 
before  bronchial  respiration  is  heard,  there  is  marked  dullness 
on  percussion,  and  this  dullness  can  be  detected  for  a  consider- 
able time  after  other  signs  of  hepatization  have  disappeared. 
Vocal  resonance  is  usually  well  marked  all  through  the  disease, 
but  vocal  fremitus  is  an  uncertain  sign,  whether  present  or 
absent.  When  present  only  on  one  side,  it  has  diagnostic 
value. 

Much  can  be  learned  by  the  general  attitude  and  behavior  of 
a  child  sick  with  pneumonia.  There  is  complete  loss  of  appe- 
tite. The  child  will  not  eat.  It  is  too  busy  trying  to  breathe 
in  a  satisfactory  manner.  It  will  drink  water,  but  thirst  is  not 
usually  urgent.  There  is  great  apathy  and  indifference,  which 
proceeds  from  exhaustion.  It  will  hold  a  toy  in  its  hand  per- 
haps for  hours  together,  making  no  complaint  and  no  requests. 
The  attention  can  be  diverted  but  momentarily  from  the  task  in 
hand,  that  of  obtaining  sufficient  oxygen  to  sustain  life.     The 


PNEUMONITIS.  559 

face  wears  an  anxious  look,  and  the  alae  nasi  work  vigorously. 
There  is  retraction  of  the  ribs  and  intercostal  spaces,  especially 
in  the  lower  and  lateral  portions  of  the  chest,  and  there  is  de- 
pression of  the  epigastrium.  The  deep  flush  on  one  or  both 
cheeks  is  rarely  absent,  but  when  on  one  side  only  it  does  not 
necessarily  correspond  with  that  of  the  lung  affected.  Certain 
nervous  symptoms  are  sometimes  observed,  but  usually  are  not 
marked,  nor  are  they  characteristic  of  the  disease.  Mild  delir- 
ium may  be  present,  and  in  severe  cases  this  may  amount  to 
acute  mania.  Persistent  drowsiness  or  stupor  are  more  com- 
mon. The  pulse  is  very  rapid,  rarely  under  one  hundred  and 
twenty,  and  sometimes  one  hundred  and  forty  or  fifty  in  the 
minute. 

The  breathing  is  also  greatly  increased  in  rapidity,  there 
being  sometimes  as  many  as  sixty,  eighty  or  even  one  hundred 
respirations  to  the  minute.  The  significance  between  the  ratio 
of  pulse  to  respiration  we  shall  speak  of  in  connection  with 
bronchitis.  The  tongue  is  usually  coated,  but  may  be  red  and 
irritable  about  the  edges.  When  the  disease  is  prolonged,  the 
mouth  and  tongue  become  dry,  and  sordes  may  collect  on  lips 
and  teeth.  Vomiting,  as  already  stated,  is  not  uncommon,  but 
is  not  usually  persistent.  Diarrhea  from  intestinal  catarrh  is 
frequently  met  with  and  is  sometimes  very  obstinate. 

Lobar  pneumonia  usually  terminates  by  crisis ;  lobular  by 
lysis. 

Etiology. — It  is  said  that  healthy  children  are  quite  as  liable 
to  attacks  of  pneumonia  as  are  those  who  are  cachectic.  This 
is  highly  improbable.  A  healthy,  rugged  child  is  more  likely 
to  resist  any  and  all  noxious  influences  than  one  who  is  not  so. 
Pneumonia  is  no  exception  to  this  rule. 

The  effect  of  bad  or  unsanitary  influences,  such  as  come  from 
living  in  basements,  unsewered  localities,  in  houses  newly  plas- 
tered, and  unhealthy  surroundings  generally,  may  be  set  down 
as  among  the  predisposing  causes.  But,  undoubtedly,  expo- 
sure to  cold,  insufficient  clothing,  damp  currents  of  air,  together 
with  dietetic  irregularities,  are  mainly  responsible  as  exciting 
causes.  The  disease  is  not  contagious,  although  it  may  appear 
in  epidemic  form,  from  a  large  number  of  children  being  ex- 
posed at  the  same  time  to  the  same  malign  influence.  Either 
one  attack  predisposes  to  others,  or  some  children  are  much 
more  susceptible  to  it  than  are  others.  It  is  no  uncommon  thing 
for  a  child  to  have  repeated  attacks.  Various  authorities  are 
cited  who  have  witnessed  a  repetition  in  the  same  individual 
of  pneumonia  as  many  as  ten  or  more  times,  the  first  attack 
occurring  in  infancy. 

Diagnosis. — The  differential  diagnosis   between  pneumonia 


560  THE  DISEASES  OF  CHILDREN. 

and  bronchitis  in  the  early  stage  of  either  disease  is  not  easy. 
It  may  be  said,  however,  that  the  early  symptoms  in  the 
former  are  more  intense  as  a  rule  than  in  the  latter.  The  fever 
is  higher  and  the  dyspnea  greater. 

Between  croupous  and  broncho-pneumonia  the  symptomatic 
line  is  not  very  clearly  drawn,  except  in  typical  cases.  There 
is  more  apt  to  be  vomiting,  chills,  headache,  delirium,  or  con- 
vulsions in  the  former  than  in  the  latter.  Broncho-pneumonia 
is  the  form  most  likely  to  follow  eruptive  fevers,  especially 
measles.  Indeed,  a  previous  history  of  measles,  whooping 
cough,  scarlatina  or  bronchitis  makes  lobular  pneumonia  prob- 
able rather  than  croupous. 

A  previous  history  of  good  health  up  to  the  time  of  seizure 
with  pneumonia  renders  it  probable  that  the  attack  is  of  the 
croupous  variety.  In  the  latter  the  ratio  of  pulse  and  respira- 
tion is  steadier,  that  is  to  say,  less  subject  to  variations  than 
the  other.  If  the  age  of  the  child  is  under  five  years,  the  type 
of  the  pneumonia  is  more  likely  to  be  lobular  than  lobar,  for  it 
is  during  the  period  of  dentition  that  broncho-pneumonia  most 
frequently  attacks  children.  After  this  period  either  form  may 
occur.  In  lobar  pneumonia  the  affection  is  usually  confined  to 
one  lung,  while  the  opposite  is  true  of  broncho-pneumonia.  In 
one  hundred  and  ninety-one  cases  cited  by  F.  Gordon  Morrill, 
evidences  of  consolidation  in  both  lungs,  were  obtained  in  only 
six  and  three-tenths  per  cent.  In  lobar  pneumonia,  the  upper 
lobes  are  more  commonly  affected  than  in  the  lobular  variety,  the 
latter  being  more  indiscriminate  in  its  preferences.  The  average 
duration  of  the  disease  is  different  in  the  two  varieties ;  that  of 
lobar  being  from  a  week  to  ten  days,  while  in  broncho-pneumo- 
nia it  is  indefinite,  but  much  longer. 

To  recapitulate :  pneumonia  occurring  under  three  years  of 
age  is  ordinarily  catarrhal,  and  is  preceded  by  and  accompanied 
with  more  or  less  bronchitis.  It  is  the  form  which  is  most  apt 
to  be  associated  with  measles,  scarlatina  and  whooping  cough. 
Lobar  or  croupous  pneumonia,  on  the  other  hand,  is  more  apt 
to  be  a  primary  disease  ;  its  beginning  more  abrupt,  and  its  du- 
ration shorter.  Whichever  form  of  pneumonitis  is  present,  the 
physical  signs  will  show  dullness  on  percussion,  bronchophony 
and  bronchial  respiration  of  higher  pitch  and  harsher  than 
the  normal  vesicular  murmur.  In  addition,  there  are  always  in 
typical  cases  the  flushed  cheek,  the  hurried  breathing,  quick 
pulse,  indifference  to  food  and  pronounced  apathy. 

Prognosis. — Pneumonia  is  one  of  the  most  fatal  of  infantile 
maladies.  No  matter  which  form  of  the  disease  may  be 
present  in  a  given  case,  the  child's  life  is  imperilled.  The  na- 
ture of  the  affection  is  such  that  it  strikes  at  the  very  citadel  of 


PNE  UMONI TIS.  561 

life.  A  child  that  cannot  breathe  cannot  live  ;  and  the  only 
reason  that  cases  do  recover  is  because  only  a  portion  of  the 
lung  structure  is  involved,  instead  of  the  whole.  In  croupous 
pneumonia  sometimes  only  small  areas  of  lung  are  involved,  and 
at  most,  in  ordinary  cases,  but  a  single  lobe.  The  affected  area 
is  limited,  and  the  consequent  damage  restricted.  There  is 
still  enough  unaffected  pulmonary  mucous  surface  to  carry  on 
the  vital  functions  of  oxygenation  and  depuration  until  resolu- 
tion is  accomplished.  Hence  the  mortality  in  this  form  of 
pneumonia  is  but  small,  especially  in  healthy,  robust  subjects. 
Barthez  publishes  a  table  of  two  hundred  and  twelve  cases  of 
pneumonia  occurring  between  the  ages  of  two  and  fifteen  years, 
with  only  two  fatalities.  But  with  catarrhal  or  broncho-pneu- 
monia, the  case  is  different.  As  we  have  seen,  it  is  most  fre- 
quent during  the  period  of  dentition,  when  the  system  is  already 
under  a  strain,  and  it  often  occurs  as  a  complication  in  diseases, 
like  measles  or  whooping  cough,  which  have  already  lowered 
the  general  tone  of  the  system  and  lessened  the  powers  of  re- 
sistance. Many  deaths  from  pneumonia  result  directly  from 
exhaustion.  Adults  in  the  vigor  of  their  maturity  are  able  to 
raise  and  expel  the  morbid  products  of  pulmonary  inflamma- 
tion before  these  products  have  had  time  to  undergo  putrefac- 
tive change  ;  but  infants  and  young  children  have  neither  the 
knowledge  nor  the  power  to  rid  themselves  of  these  mischievous 
secretions.  Hence  the  mortality  from  broncho-pneumonia  is 
large,  and  the  younger  the  subjects,  other  things  being  equal, 
the  greater  the  mortality.  Just  what  the  ratio  of  deaths  to 
cases  is,  is  uncertain.  Some  authorities  place  it  as  high  as  fifty 
per  cent.  This  is  probably  much  too  high  in  cases  treated  hom- 
eopathically.  I  have  a  record  of  twenty-two  cases,  with  but 
three  deaths.  The  average  age  of  these  cases  was  two  and 
three-quarter  years.     All  of  them  occurred  in  private  practice. 

Any  exhaustive  disease  preceding  or  accompanying  the  pneu- 
monia increases  its  danger,  and  the  younger  the  child  and  more 
feeble  the  constitution,  the  less  likelihood  there  is  of  recovery. 
Unfavorable  symptoms  are  increasing  rapidity  and  feebleness 
of  the  pulse,  pallor  of  countenance,  inability  of  the  patient  to 
support  the  head,  showing  inordinate  weakness ;  refusal  to  no- 
tice or  be  amused  with  toys  ;  absence  of  tears  when  crying ; 
and  the  appearance  of  pemphigus  on  the  face  or  elsewhere. 

Symptoms  on  which  a  favorable  prognosis  may  be  based  are 
moderate  acceleration  of  pulse ;  retained  ability  to  support  the 
head  ;  decided  and  permanent  lowering  of  the  temperature ; 
desire  for  food  ;  return  of  tears  after  they  have  been  absent, 
etc.  When  the  inflammation  begins  to  abate,  there  is  generally 
progressive  improvement ;  but  the  danger  of  relapse  must  not 
D.  C— 36 


562  THE  DISEASES  OF  CHILDREN. 

be  forgotten,  and  supportive  measures  will  be  necessary  to 
combat  the  tendency  to  asthenia. 

Treatment. — The  latter  part  of  the  last  sentence  should  have 
been  printed  in  italics  or  small  capitals,  the  more  to  impress 
the  young  practitioner  with  one  of  the  great  dangers  to  be  en- 
countered in  this  disease.  Before  the  benign  help  and  influence 
of  homeopathy  came  to  the  rescue  of  suffering  humanity,  blood- 
letting, mercurials,  blisters,  antimony,  and  other  depressants 
carried  off  more  victims  than  the  inflammation  itself.  While 
the  main  dependence  is  to  be  placed  on  the  indicated  remedies, 
the  tendency  to  exhaustion  must  not  be  lost  sight  of  for  a  mo- 
ment. Such  diffusible  stimulants  as  brandy,  whisky,  ammonia, 
etc.,  may  avert  impending  suffocation,  and  give  time  for  the 
chosen  remedy  to  act. 

We  have  seen  such  salutary  results  from  the  judicious  use 
of  hot  fomentations  of  the  chest  with  flannel  wrung  out  of  hot 
water  and  hot  poultices  of  linseed  meal,  that  we  would  not 
treat  a  case  of  capillary  bronchitis  or  pneumonia  without  one 
or  the  other  of  them.  Poultices  are  preferable,  because  they 
retain  their  heat  longer,  and  do  not  wet  the  clothing.  They 
should  be  covered,  as  soon  as  applied,  with  a  layer  of  oil-silk, 
in  order  to  retain  the  heat  as  long  as  possible,  and  they  should 
be  changed  or  re-applied  as  soon  as  cool. 

Internal  Remedies. — These  are  not  very  numerous,  but  are 
wonderfully  effective.  We  shall  drop  the  alphabetical  arrange- 
ment of  drugs  here  and  name  them,  for  better  perspicuity,  in 
the  order  of  their  relative  value. 

Tartar  Emetic.  —  In  well-established  cases,  especially  of 
broncho-pneumonia,  this  remedy  is  paramount  to  all  others.  It 
comes  the  nearest  to  being  a  true  similimumto  all  of  the  essen- 
tial features  of  the  disease,  viz.,  loose,  mucus  cough  ;  great 
oppression  in  breathing  ;  quick,  hurried  respiration  ;  crepitant 
rale ;  mucus  ronchus ;  great  anxiety  of  countenance ;  vomit- 
ing ;  anorexia.  It  should  be  given  in  the  third  decimal  tritu- 
ration, two  to  three  grains  in  a  tumbler  half  filled  with  water, 
of  which  a  teaspoonful  may  be  given  every  hour,  half-hour, 
or  in  urgent  cases,  every  fifteen  minutes,  until  symptoms 
ameliorate. 

Phosphorus.  —  Incessant,  short,  dry,  hacking  cough;  scant 
secretion  in  the  bronchi  ;  crepitant  rale ;  dryness  of  air  pas- 
sages ;  bronchial  respiration  ;  collapse  of  lung  ;  short,  laborious 
breathing ;  rapid  prostration  ;  sunken  features ;  dry  lips  and 
tongue ;  involuntary  diarrhea ;  threatened  paralysis  of  lungs  ; 
hepatization  of  the  lower  half  of  right  lung.  Pleuro-pneumonia, 
with  extensive  implication  of  the  pleura.  (Bry.)  "  Phosphorus 
is  our  great  tonic  to  the  heart  and  lungs." — Lilienthal. 


PNE  UMONI TIS— REMEDIES.  563 

Aconite. — First  stage,  hot,  dry  skin  ;  arterial  thrill ;  sibilant 
ronchus  ;  hasty  respiration  ;  agitated  manner ;  pulmonary  hy- 
peremia ;  percussion  sound  still  clear  and  crepitating  rales  dis- 
tinctly audible.  Aconite  is  of  little  use  after  stage  of  hepati- 
zation is  fully  inaugurated. 

Gelse^nium. — High  fever  without  thirst;  intermittent  parox- 
ysms of  hoarseness,  and  voice  becomes  very  weak  ;  sighing  res- 
piration ;  local  pains  on  both  sides  under  scapula ;  especially 
valuable  in  pneumonia  following  eruption  of  measles  ;  pulse 
slow  and  full  ;  short  paroxysms  of  pain  in  superior  part  of  right 
lung,  on  taking  a  deep  breath  ;  nausea,  vomiting. 

Bryonia. — Great  dyspnea,  aggravated  by  the  slightest  motion  ; 
pleuro-pneumonia ;  short,  jerky,  incomplete  respiration  ;  tho- 
racic tenderness ;  tongue  foul ;  gastric  catarrh  ;  thirst  for  large 
quantities  of  water ;  abdominal  breathing ;  inclination  to  lie 
perfectly  still. 

Cuprum. — Pneumonia  complicating  whooping  cough  ;  begin- 
ning paralysis  of  lungs  with  sudden  difficulty  of  breathing, 
which  is  followed  by  great  prostration  ;  the  face  is  earthy,  dirty- 
bluish  ;  roof  of  mouth  red.  There  may  be  diarrhea,  connected 
with  sour-smelling  perspiration  (Deschere),  when  formation  of 
abscess  threatens. 

Cannabis  Sativa. — Constant  delirium  during  the  fever,  with 
hard,  teasing,  sometimes  incessant  cough  (phos.),  and  vomiting 
of  bilious,  greenish  matter  ;  the  pulse  is  weak,  frequently  al- 
most imperceptible  ;  violent  palpitation  of  the  heart  on  moving 
the  body.  Lobar  pneumonia :  lung  lesion  limited  to  one  lobe 
or  to  one  side. 

Opium. —  Pulmonary  inflammation  disguised  by  symptoms  of 
cerebral  congestion  and  oppression  ;  cyanotic  color  of  upper 
part  of  body,  with  slow,  stertorous  breathing ;  anxious  sleep 
with  starts  (bell.) ;  hot  perspiration  all  over  the  body,  except 
lower  limbs  ;  parts  covered  by  a  heavy  crop  of  sudamina.  The 
patient  gropes  with  his  hands  around  the  bed  as  though  he 
were  hunting  for  something. — Hoyne. 

Sanguinaria. — This  remedy,  according  to  Hale,  occupies  a 
middle  ground  between  tartar  emetic  and  phosphorus.  Dr. 
Hale  says  of  it,  in  this  connection  :  "  It  has  many  symptoms  in 
common  with  both,  and  others  possessed  by  neither.  The  gen- 
eral symptoms  indicating  sanguinaria  are  extreme  dyspnea, 
short,  accelerated,  constrained  breathing ;  the  pulse  is  quick 
and  small,  the  face  and  extremities  are  inclined  to  be  cold,  or 
the  hands  and  feet  burning  hot,  with  circumscribed  redness  and 
burning  heat  of  the  cheeks,  especially  in  the  afternoon.  The 
patient  lies  upon  the  back  and  is  most  comfortable  with  the 
head  elevated ;  the  dry  cough  will  awaken  the  patient  out  of 


564  THE  DISEASES  OF  CHILDREN. 

sleep,  and  will  not  cease  until  he  sits  up  in  bed.  There  is  fre- 
quent gaping  after  the  cough." 

Belladonna,  hyoscyamus,  are  the  chief  remedies  for  the  de- 
lirium which  so  frequently  complicates  pneumonia,  when  it  is 
due  to  arterial  or  venous  congestion.  They  can  be  considered 
merely  as  intercurrent  remedies,  when  the  upper  portion  of  the 
lung  is  involved  and  the  delirium  is  directly  referable  to  circu- 
latory disturbance,  and  not  to  blood  change,  and  especially  if 
the  head  symptoms  are  prominent  from  the  start.  Belladonna 
may  be  given  at  once,  and  with  better  effect  than  aconite. 
Hyoscyamus  is  especially  valuable  in  hypostatic  pneumonia, 
with  delirium,  not  so  violent  in  form  as  that  of  belladonna. 
There  is  less  congestion,  but  more  nervous  excitement,  with 
talkativeness  and  hallucinations,  under  hyoscyamus. 

Mercurius. — General  flagging  of  vital  energies ;  dullness  over 
lung  on  percussion  ;  absence  of  respiratory  murmur  and  crepi- 
tant rales ;  bronchial  ronchus  ;  livid  expression  of  countenance. 
All  these  symptoms  indicate  consolidation  of  the  part  involved. 
The  cough  in  bell.,  hyos.  and  mercurius  is  in  all  three  remedies 
aggravated  at  night.  Besides  the  remedies  here  enumerated, 
attention  is  called  to  veratrum  viride,  digitalis,  ipecac,  kali 
bichromicum,  kali  carbonicum,  cina,  spongia^  lycopodiumy  etc. 


CHAPTER  VIII. 

BRONCHITIS    (bronchial  CATARRH). 

Definition. — Bronchitis  is  an  inflammation  of  the  mucous 
lining  of  the  bronchial  tubes,  attended  with  more  or  less  exu- 
dation of  mucus  in  excess  of  normal  requirements.  It  may 
be  either  acute  or  chronic.  When  it  affects  the  bronchioles, 
which  are  the  ultimate  divisions  of  the  bronchial  tree  from 
which  the  air  cells  begin  to  be  given  off,  it  is  called  "  capillary 
bronchitis."  This  form  of  bronchitis  will  be  treated  of  in  a 
separate  section. 

Etiology. — Whatever  confusion  and  murkiness  may  have 
clouded  the  etiological  atmosphere  surrounding  pneumonitis, 
are  dispelled  when  we  come  to  consider  the  causes  producing 
an  inflammation  of  the  bronchial  tubes.  All  mucous  mem- 
branes everywhere  are  liable  to  congestion  and  inflammation 
from  the  effects  of  cold,  dampness  and  dust,  or  anything,  in 
fact,  which  may  set  up  an  irritation  in  their  surfaces.  We  have 
cystitis  from  acrid  kidney  secretions ;  diarrhea  from  the  inhibi- 
tion of  indigestible  food,  or  from  the  effect  of  cold  and  damp- 
ness, checking  the  exhalations  from  the  skin  and  forcing  them 
to  find  an  exit  through  the  intestinal  mucous  membranes.  The 
relations  between  the  skin  and  the  bronchial  lining  are  still 
more  close  and  intimate,  and  any  shock  to  the  skin  is  liable  to  be 
felt  at  once  by  the  pulmonary  mucous  lining.  A  slight  draught, 
a  sudden,  although  slight  change  in  the  temperature,  will  often 
excite  irritation  in  the  schneiderian  membrane,  and  cause  sneez- 
ing, which  may  be  the  commencement  of  an  acute  coryza,  an 
angina  or  a  bronchitis.  Steady,  dry  cold  does  not  seem  to  act 
as  a  cause  of  pulmonary  inflammation,  as  it  is  said  to  be  a  rare 
complaint  in  the  arctic  regions  in  winter.  Along  the  sea-coast 
and  in  our  lake  regions,  catarrhs  of  all  kinds  are  endemic,  but 
are  of  most  frequent  occurrence  during  the  spring  and  autumn 
months,  when  the  atmosphere  is  often  saturated  with  moisture, 
and  the  temperature  is  subject  to  sudden  and  marked  varia- 
tions. Superheated  houses,  by  relaxing  the  skin  and  causing 
draughts,  are  hot-beds  of  catarrh.  There  is  always  more  dan- 
ger from  excessive  than  from  deficient  heating  of  homes.  Im- 
pure air,  from  whatever  source,  or  however  produced,  is  an 

(565) 


566  THE  DISEASES  OF  CHILDREN. 

irritant  to  the  respiratory  mucous  membranes,  and  paves  the 
way  for  bronchitis  or  pneumonia. 

The  period  of  first  dentition  is  one  during  which  children  are 
especially  liable  to  catarrhs  of  all  kinds.  The  respirator}''  tract 
affords  no  exception  to  the  rule. 

A  cold  in  the  head,  or  a  mild  laryngitis,  if  neglected,  is  very 
liable  to  creep  along  down  into  the  bronchi  and  develop  there 
an  inflammation  of  greater  or  less  extent.  Certain  diseases, 
such  as  the  eruptive  fevers  (notably  measles),  which  alter  the 
quality  of  the  blood  and  reduce  the  general  tone  of  the  system, 
are  very  often  accompanied  or  followed  by  bronchitis.  Indeed, 
it  may  be  said  that  more  or  less  bronchitis  is  always  associated 
with  measles.  Whooping  cough  is  also  usually  accompanied 
with  some  catarrh  of  the  bronchial  mucous  membrane.  Doubt- 
less there  are  other  causes  of  bronchial  inflammation,  of  which 
we  know  little  or  nothing,  such  as  electrical  and  telluric  dis- 
turbances, barometric  changes,  and  the  like,  which  at  times 
make  such  trouble  epidemic.  With  so  many  etiological  fac- 
tors as  those  well  known  and  generally  recognized,  it  is  no 
wonder  that  bronchitis  is  one  of  the  commonest  affections  of 
childhood.  It  is  most  commonly  met  with  as  a  disease  of  the 
large  and  medium-sized  tubes,  and  as  such  we  shall  consider  it 
here. 

Symptoms. — In  many,  perhaps  most,  cases  of  bronchitis  oc- 
curring in  children  under  five,  there  is  an  accompanying  or  pre- 
ceding catarrh  of  nose  and  throat.  Its  onset  may,  however,  be 
sudden  and  without  warning  or  complication.  There  is  high 
fever  (102°  or  103°),  labored  breathing,  quick  pulse  and  a  fre- 
quent short,  dry,  hacking  cough,  which  subsequently  becomes 
moist  and  rattling.  The  tongue  is  thickly  furred.  In  nursing 
babies  the  coryza  obstructs  the  breathing  power,  and  makes 
them  constantly  let  go  the  nipple  to  take  breath.  It  is  said 
that  a  child  that  can  scream  long  and  loud  cannot  have 
pneumonia  ;  and  it  is  equally  true  that  an  infant  who  can  nurse 
without  interruption  on  account  of  "  catching  the  breath," 
cannot  have  bronchitis. 

Bronchitis  of  mild  type,  that  in  which  only  the  larger  bron- 
chial tubes  are  affected,  is  common  to  all  periods  of  infancy  and 
childhood.  In  the  beginning,  the  respiration  and  pulse  are 
scarcely  accelerated,  and  the  appetite  is  but  little  impaired. 
Auscultation  in  these  mild  cases  reveals  coarse  mucus  rales  in 
the  larger  bronchial  tubes,  while  the  smaller  ones  are  free  from 
mucus.  Sibilant  and  sonorous  rales  are  also  observed,  especially 
in  the  commencement  of  the  disease,  when  the  secretion  of 
mucus  is  suppressed  or  scanty.  By  the  second  or  third  day, 
and  usually  sooner  under  appropriate  treatment,  the  cough 


BRONCHITIS.  567 

becomes  looser  and  the  sputa,  if  obtainable,  will  be  found  to 
consist  of  frothy  mucus,  with  an  admixture  of  pus  and  epithelial 
cells.  As  the  disease  continues,  the  pus  becomes  more  abund- 
ant. The  duration  of  these  symptoms  may  be  from  two  or 
three  days  to  a  week  or  more.  In  rare  instances  the  bronchitis 
fails  to  yield  to  treatment,  and  takes  on  a  chronic  form  which 
may  last  indefinitely.  The  disease  may  be  either  primary — that 
is,  unassociated  with  any  other  disease — or  it  may  be  secondary 
to  coryza,  laryngitis,  pharyngitis  ;  to  measles,  whooping  cough, 
or  any  of  the  continued  or  remittent  fevers. 

Prognosis. — When  bronchitis  is  confined  to  the  larger  or 
TTiedium-sized  tubes,  is  uncomplicated,  and  occurs  in  a  previously 
healthy  child,  having  good  surroundings  and  good  care,  the 
prognosis  is  always  favorable.  In  other  cases,  with  poor  sur- 
roundings and  poor  care,  and  occurring  in  a  child  already 
enfeebled  by  acute  or  chronic  disorders,  the  prognosis  should 
be  guarded.  It  should  not  be  forgotten  that  there  is  always 
danger  of  a  mild  and  simple  bronchitis  extending  into  the 
bronchioles  and  the  alveoli,  and  producing  or  becoming  that 
much  more  serious  malady,  capillary  bronchitis,  or,  as  some 
authors  prefer  to  call  it,  broncho-pneumonia. 

Diagnosis. — The  diagnosis  of  bronchitis  is  usually  unattended 
with  difficulty.  The  respiration  is  not  hurried  and  labored,  as 
it  is  in  pneumonia.  Auscultation  discovers  coarse  mucus 
rales,  if  the  larger  tubes  are  involved,  and  fine,  subcrepitant 
rales,  if  the  smaller  tubes  are  affected.  Percussion  gives  clear 
resonance  on  both  sides,  except  in  those  cases  in  which  collapse 
of  lung  or  pneumonia  has  superseded.  The  absence  of  hoarse- 
ness, stridulous  inspiration,  and  croupy  cough  distinguishes  it 
from  laryngitis  ;  and  the  stitch-like  pain  which  belongs  to 
pleurisy  is  wanting. 

Treatment. — To  go  over  the  list  of  remedies  suitable  for 
bronchitis,  would  be  to  reiterate  what  has  already  been  said  in 
the  previous  section  and  in  the  remarks  introducing  the  subject 
of  respiratory  diseases.  The  reader  is  referred  particularly  to 
pages  512,  514,  where  the  repertory  of  cough  remedies  is  very 
full  and  complete.  There  are  no  special  remedies  for  bronchitis 
that  have  not  been  already  mentioned  and  their  special  indica- 
tions pointed  out.  Whatever  omission  there  may  be,  if  any, 
in  these  previous  sections,  will  be  supplied  in  the  following 
section  on  Capillary  Bronchitis. 

In  saying  this,  it  must  not  be  inferred  that  the  simple  form 
of  bronchitis  here  considered,  is  unworthy  of  serious  and  care- 
ful treatment.  On  the  contrary,  a  mild  and  apparently  inno- 
cent inflammatory  catarrh  of  the  large  and  medium-sized  tubes 
may,  if  neglected,  extend  to  the  bronchioles  and  the  air  cells, 


568  THE  DISEASES  OF  CHILDREN. 

and  speedily  result  in  a  broncho-pneumonia  of  serious  aspect, 
or  take  on  a  chronic  form,  with  its  possibilities  of  eventuating 
in  phthisis  pulmonalis,  asthma,  emphysema,  or  collapse  of  the 
lungs  (atelectasis). 

CAPILLARY   BRONCHITIS. 

This  term  is  used  to  indicate  a  form  of  bronchitis  affecting 
principally  the  finer  or  finest  ramifications  of  the  bronchial  tree, 
just  before  the  air  vesicles,  or  alveoli,  are  given  off. 

The  term  is  objected  to  by  some  hypercritical  authorities, 
who  have  suggested,  as  more  indicative  of  its  morbid  anatomy, 
the  term  "bronchiolitis;"  others  have  endeavored  to  substi- 
tute the  term  "  terminal  bronchitis  "  as  more  expressive  and 
correct.  To  our  own  mind,  neither  of  these  expressions  is  less 
open  to  criticism  than  that  of  capillary  bronchitis.  In  many 
cases  where  the  bronchioles  are  manifestly  affected,  the  inflam- 
matory process  stops  short  of  the  termini,  in  which  cases  "  ter- 
minal "  bronchitis  would  not  apply.  "  Bronchiolitis  "  is  perhaps 
less  objectionable,  but  we  can  see  no  particular  advantage  in 
substituting  a  new  term  for  an  old  and  time-honored  one,  when 
the  one  is  just  as  definite  and  comprehensive  as  the  other. 

Retaining  then,  the  old  term,  capillary  bronchitis,  out  of 
respect  for  its  age,  if  nothing  more,  let  us  see  what  the  term 
implies. 

We  have  already  seen  pointed  out  that  in  the  ordinary  and 
simple  form  of  bronchitis,  affecting  the  large  or  medium-sized 
tubes,  we  have  an  inflammation  of  the  mucous  lining  of  these 
tubes,  eventuating  in  a  catarrhal  effusion  upon  the  tubular  sur- 
faces, attended  by  cough  and  expectoration.  There  is  no  ob- 
struction to  respiration,  or  next  to  none,  because  the  caliber  of 
the  affected  tubes  is  not  completely  filled  by  the  effused  mucus. 
In  other  words,  there  is  no  stenosis  or  occlusion.  When,  how- 
ever, the  minute  bronchioles  are  invaded,  the  case  is  very  dif- 
ferent. On  account  of  the  narrowness  of  the  tube,  the  inflam- 
matory swelling  of  the  lining  membrane  of  the  bronchioles  is 
sufficient  alone  to  produce  suffocative  attacks  (bronchitis 
sicca).  In  these  finer  air  tubes,  mucus  or  pus  has  precisely  the 
same  effect  as  dense  fibrinous  material  has  in  the  larger  tubes. 
Air  cannot  penetrate  beyond  the  obstruction  and  enter  the  air 
vesicles,  which  are  almost  certain  to  collapse  in  consequence. 
In  case  the  air  cells  do  not  collapse,  the  contiguous  inflamma- 
tion is  tolerably  sure  to  invade  them,  with  consequent  exuda- 
tion and  infiltration.  The  inspired  air  cannot  reach  the  blood, 
and  decarbonization  of  this  fluid  is  as  effectually  arrested  as  if 
the  larynx  or  trachea  were  plugged  with  a  pseudo-membrane. 


CAPILLARY  BRONCHITIS.  569 

The  danger  from  capillary  bronchitis  is  in  direct  proportion  to 
the  number  of  bronchioles  affected.  From  a  pathological 
standpoint,  capillary  bronchitis  and  simple  bronchitis  are  pre- 
cisely the  same  thing ;  the  latter  affecting  the  larger  or  medium 
tubes,  the  former  affecting  the  smaller  and  finer.  There  is  no 
difference  at  all  in  the  process,  except  one  of  grade.  Capillary 
bronchitis  is  essentially  a  disease  of  infancy.  It  may  be  pri- 
mary, the  bronchioles  being  involved  from  the  start ;  or  it  may 
arise  from  extension  of  the  inflammation,  which  has  primarily 
affected  the  larger  tubes. 

Symptoms  and  Course. — In  capillary  bronchitis  the  symptoms 
are  much  more  intense  than  in  the  ordinary  form  of  the  disease. 
The  dypsnea  is  greater,  the  fever  is  higher,  and  there  is  a 
greater  degree  of  restlessness  and  anxiety.  The  difficulty  of 
breathing,  in  these  cases,  arises  from  two  sources  :  one,  the 
swelling  of  the  membrane  lining  the  bronchioles  ;  the  other, 
the  secretion.  The  latter  may  be  small  in  amount,  in  which 
case  the  dypsnea  will  be  but  moderate  ;  but  when  there  exists 
an  extensive  implication  of  the  bronchi,  it  increases  to  a  severe 
degree,  and  suffocative  attacks  with  cyanosis  ensue  ;  the  victims 
are  unable  to  breathe  unless  they  are  raised  ;  the  nostrils  dilate, 
and  the  alze  nasi  work  spasmodically,  as  they  do  in  broncho- 
pneumonia. The  cough  is  violent  and  distressing,  but  not  so 
painful  as  in  pleurisy  or  pleuro-pneumonia.  It  may  occur  in 
paroxysms,  or  be  more  or  less  continuous.  The  rapidity  of  respi- 
ration is  greatly  increased,  sometimes  reaching  as  many  as  sixty, 
eighty,  or  even  more  per  minute.  In  this  connection  Dr.  Mar- 
tin Deschere  makes  the  point  that,  "  In  young  subjects  espe- 
cially, forty  to  fifty  respirations  per  minute  may  be  observed 
without  necessarily  denoting  great  danger.  But  if  a  rise  to 
sixty  or  eighty  and  more  respirations  takes  place,  it  is  a  sure 
sign  that  the  finer  tubes  have  become  involved." 

The  quicker  the  respiratory  movements,  the  shorter  and  more 
superficial  will  they  be.  At  the  same  time,  inspiration  becomes 
more  labored,  all  the  auxiliary  muscles  are  brought  into  play, 
and  the  presence  of  a  moan  with  each  expiration  is  pathog- 
nomonic of  grave  respiratory  affection.  Percussion  even  now 
will  be  normal,  but  auscultation  will  give  rattling  noises  of  all 
kinds  and  qualities,  as  the  large  tubes  participate. 

The  relation  of  respiration  to  pulse  is  of  great  importance. 
It  may  change  from  the  normal  ratio  of  one  respiration  to  three 
or  four  beats  of  the  heart,  to  one  respiration  to  two  beats  or 
less,  according  to  the  severity  of  the  attack.  As  long  as  this 
relation  does  not  exceed  one  to  two  (with  a  pulse  of  140-150 
in  children  under  two  years),  we  need  not  be  alarmed  ;  but 
if  it  becomes  closer  than  one  to  two,  there  will  be  danger  of 


570  THE  DISEASES  OF  CHILDREN. 

collapse ;  and  if  respiration  reaches  lOO,  with  a  pulse  of  two 
hundred  or  more,  paralysis  of  the  heart  may  set  in  from  over- 
strain, though  here  the  ratio  is  but  one  to  two. 

Henoch  is  accredited  with  a  diagnostic  point  which  is  w^orth 
remembering.  He  says,  "Children  who  are  able  to  nurse  un- 
interruptedly, without  stopping  to  take  breath,  have  either 
acute  coryza  or  capillary  bronchitis."  He  values  this  symptom 
of  uninterrupted  nursing  so  highly,  that  he  advises  always  hav- 
ing the  child  put  to  the  breast  in  the  presence  of  the  physician 
while  making  his  examination,  to  enable  him  to  judge  of  its 
manner  of  nursing. 

Deschere  advises  that  "Children  from  one  to  three  years  of  age 
should  be  examined  while  in  an  upright  position  (sitting  on  the 
mother's  or  nurse's  lap).  Here  a  little  kindness  and  tact  will 
generally  succeed,  except  in  *  crude-antimony '  children,  who 
do  not  want  to  be  touched.  But  this  very  peculiarity  is  an 
excellent  indication  for  the  drug,  under  the  influence  of  which 
our  patient  is  safe  until  the  next  visit,  when  he  will  be  found 
of  a  more  amiable  disposition." 

"  The  cough,  although  a  most  prominent  symptom,  is  not  a 
reliable  guide  to  the  severity  of  the  affection.  There  may  be 
extensive  inflammation  of  the  bronchi  or  the  bronchioles,  as 
evidenced  by  the  pulse,  temperature,  respiration  and  physical 
signs,  and  yet  the  cough  be  suppressed.  Again,  during  conva- 
lescence, there  may  be  a  continuous  and  most  harassing  cough, 
exhausting  to  the  child,  while  at  the  same  time,  all  the  other 
symptoms  may  be  most  favorable.  The  temperature  in  capil- 
lary bronchitis  will  not  rise  above  103°  Fahr.,  unless  the  air 
cells  are  themselves  involved,  constituting  the  disease  one  of 
broncho-pneumonia;  but  we  cannot  positively  deny,  in  a  given 
case,  the  presence  of  pneumonia,  although  the  temperature 
may  be  below  104°.  All  observers  agree  on  the  unsatisfactory 
results  of  percussion  in  this  form  of  pneumonia,  and  if  we  con- 
sider the  gradual  and  dispersed  manner  in  which  the  inflamma- 
tion spreads  into  the  air  cells,  affecting  only  small  points  at 
one  time,  these  results  are  easily  understood  "  (Deschere  in 
Hahnemannian  Monthly,  Sept.,  1 882).  Among  the  other  and  gen- 
eral symptoms  which  are  to  be  noticed  in  this  connection,  is 
epigastric  pain.  It  is  not  of  great  significance,  for  sick  children 
are  proverbial  for  having  aches  and  pains,  which  they  rarely 
locate  at  the  seat  of  disease,  or  even  that  of  real  distress.  Ow- 
ing to  the  age  of  the  child  when  capillary  bronchitis  is  most 
common,  it  is  not  always  possible  to  obtain  the  sputa.  It  is  in 
most  instances  swallowed  into  the  stomach,  where  it  undergoes 
change  before  it  is  vomited  up.  It  is  sometimes  possible,  how- 
ever, during  a  fit  of  coughing,  to  throw  the  child  forward,  and 


CAPILLARY  BRONCHITIS.  571 

thus  secure  enough  for  examination  upon  a  cloth.  At  first  the 
secretion  is  tough  and  tenacious ;  afterwards  it  becomes  muco- 
purulent and  thinner.  It  is  usually  yellowish-white  in  appear- 
ance, and  often  looks  like  foam,  mixed  with  thin  threads,  from 
the  minute  bronchioles  of  which  they  are  casts. 

The  temperature  in  this  affection,  as  has  been  already  ob- 
served, is  higher  than  in  the  ordinary  form  of  bronchitis,  but 
not  so  high  as  in  pneumonia.  By  careful  observation  it  is  often 
possible  to  note  the  transition  from  most  extensive  capillary 
bronchitis  to  broncho-pneumonia.  The  increased  temperature 
which  accompanies  such  a  transition  is  very  obvious.  A  com- 
paratively circumscribed  pneumonitis  will  give  rise  to  a  rapid 
■elevation  of  temperature  much  more  quickly  than  even  a  diffuse 
bronchial  catarrh,  even  though  implicating  the  finer  tubes. 
Gastric  disturbances  are  common.  There  is  complete  loss  of 
appetite,  coated  tongue,  and  sometimes  vomiting  of  mucus. 
The  bowels  are  apt  to  be  constipated  at  first,  while  later  diar- 
rhea, excited  by  the  swallowing  qf  so  much  mucus,  is  the  rule. 
In  the  severer  grades,  defective  aeration  of  the  blood  is  ob- 
served, the  respiratory  process  is  insuflficient,  and  gradual 
suffocation  ensues.  The  blood  is  charged  with  carbonic-acid 
gas,  and  its  oxygen  is  correspondingly  deficient ;  the  cyanosis 
deepens,  the  face  is  turbid,  bloated,  dusky,  or  livid.  The  lips, 
tip  of  the  nose,  malar  protuberances,  tongue  and  ears  are  very 
livid,  and  in  marked  contrast  with  the  pallor  of  the  surrounding 
skin.  The  veins  of  the  head  and  neck  swell.  The  fingers  and 
toes,  especially  the  nails,  show  also  the  cyanosis ;  the  feet  and 
hands  may  become  edematous.  The  temperature  falls,  clammy 
sweats  break  out,  particularly  about  the  face,  and  then  involve 
the  whole  body.  The  patient  is  exhausted,  the  head  drops 
about  in  any  direction.  The  pulse  is  very  rapid,  weak,  small, 
compressible,  and  often  irregular.  The  patient  is  restless ;  there 
is  an  anxious  expression  of  countenance,  which  continues  until 
the  mind  begins  to  wander,  and  the  patient  grows  dull  and 
apathetic,  falling  into  a  drowsy  state ;  then  a  stupor,  and  finally 
a  complete  coma  ensues,  which  precedes  death.  In  some  chil- 
dren there  may  be  convulsions.  The  cough  is  not  severe,  and 
no  attempt  is  made  at  expectorating ;  the  breathing  is  very 
rapid,  and  gradually  grows  more  shallow.  Bronchial  rales  are 
plainly  audible,  and  as  the  large  tubes  become  filled,  there  is 
distinct  crackling.  Death  occurs  either  from  blocking  up  the 
large  bronchi  suddenly,  or  from  extensive  pulmonary  collapse, 
congestion  giving  rise  to  edema,  or  from  lobular  or  lobar  pneu- 
monia. 

Diagnosis. — From  what  has  already  been  said,  the  diagnosis 
of  capillary  bronchitis  can  only  be  obscured  when  it  verges  on 


572  THE  DISEASES  OF  CHILDREN. 

that  diaphanous  or  hypothetical  line  which  divides  it  from 
broncho-pneumonia.     The  distinction  is  not  important. 

The  difference  is  merely  one  of  degree.  In  capillary  bron- 
chitis, the  rales  are  usually  more  diffuse  and  of  larger  size, 
while  in  lobular  pneumonia  they  are  limited  to  the  affected 
space,  usually  at  the  bases  of  the  lungs,  where  they  are  irregu- 
larly scattered.  In  lobular  pneumonia  we  have  more  frequent 
respirations  and  less  dyspnea,  and  less  tendency  to  cyanosis. 
The  temperature  in  pneumonia  is  higher,  and  dullness  on  per- 
cussion is  more  marked. 

The  duration  of  capillary  bronchitis  is  usually  four  or  five 
days,  but  may  be  longer.  The  fatal  cases  occur  usually  about 
the  sixth  to  the  eighth  day.  The  symptoms  which  indicate  a 
fatal  termination  are  great  lividity  of  countenance,  cyanosis, 
coldness  of  extremities,  dullness  of  comprehension,  coma  and 
convulsions.  Favorable  signs  are  lowering  of  temperature, 
greater  ease  in  breathing,  ability  to  nurse,  desire  for  food,  bet- 
ter color  of  countenance,  increased  strength. 

Prognosis. — Capillary  bronchitis  is  always  a  grave  disease,  but 
under  appropriate  treatment,  even  those  cases  which  seem  to 
be  the  most  desperate  oftentimes  recover. 

To  the  unwary  the  disease  is  full  of  surprises,  and  every  case 
demands  the  closest  attention  of  both  physician  and  attendants. 
To  the  weakling,  the  affection  is  one  full  of  hazard,  and  to  the 
robust  is  not  without  danger.  The  prognosis  should,  therefore, 
be  guarded  but  hopeful. 

Treatment. — An  even  and  equable  temperature  should  be 
maintained  in  the  room  of  the  patient  —  70°  or  72°  Fahr.  is 
about  right.  Moisture  of  air  favors  expectoration  and  dimin- 
ishes the  cough.  Inhalations  of  steam  are,  therefore,  beneficial. 
A  jacket  of  cotton-wool  may  be  made  to  lightly  envelope  the 
chest,  or  still  better,  a  jacket-poultice  of  linseed  meal  may  be 
used,  and  kept  warm  and  moist  by  an  outer  envelop  of  oil  silk. 
If  poultices  are  used,  they  should  be  renewed  as  soon  as  cool, 
for  they  are  only  of  use  when  moist  and  warm.  When  taken  off, 
they  should  be  replaced  with  cotton-wool,  or  absorbent  cotton. 

The  main  dependence  in  the  conduct  of  a  case  of  capillary 
bronchitis,  however,  must  be  in  the  homeopathic  remedy,  and 
the  indications  for  certain  drugs  have  been  so  admirably  given 
in  a  paper  read  before  the  American  Pedological  Association 
by  Dr.  Deschere,  some  years  ago,  that  we  are  impelled  to  make 
use  of  them  here,  for  the  benefit  of  our  readers. 

In  doing  so  we  desire  to  express  our  obligations  to  the  au- 
thor for  the  liberty  taken  : 

"  The  keynotes  for  the  selection  of  the  homeopathic  remedy 
must  be  looked  for  in  the  character  of  the  cough,  the  manner 


CAPILLARY  BRONCHITIS.  573 

of  breathing,  its  character  and  frequency,  the  mental  condition 
and  the  sleep. 

"After  that  we  must  take  into  consideration  the  general  ap- 
pearance, as  to  constitution,  and  grade  of  prostration,  the  ex- 
tent of  the  affection,  manifestation  of  fever,  pulse,  temperature, 
appetite,  thirst,  stool,  urine,  etc. 

"  The  first  line  of  symptoms  will  give  the  most  characteristic 
indications,  as  they  contain  the  individual  peculiarities;  while 
the  latter  ones  are  of  more  general  value,  and  will  only  confirm 
or  rarely  modify  our  choice  of  the  remedy.  Still,  they  must  all 
be  weighed  according  to  their  prominence  and  mutual  relation. 

"  To  begin  at  the  beginning,  I  must  say  that  two  grave  mis- 
takes are  frequently  made  with  aconite,  the  remedy  par  excel- 
lence '  when  the  fever  runs  high.' 

"  The  second  mistake  is  to  change  aeon,  for  another  remedy 
when  the  fever  decreases  and  the  cough  becomes  loose. 

"  So  long  as  aeon,  produces  such  a  favorable  change,  why 
not  continue  it,  as  we  would  any  other  drug  under  the  same 
circumstances?  But  if  our  patient  has  received  enough  of  it, 
and  is  improving,  then  stop  all  medication,  and,  if  necessary, 
give  sac.  lac. 

"  The  indications  for  aeon,  should  be  more  precise  than  those 
furnished  by  high  fever,  dry  cough,  and  great  restlessness,  which 
it  shares  with  other  remedies.  There  should  be  present  a  short, 
dry,  hacking,  or  sometimes  ringing  cough,  worse  after  drinking 
cold  water,  and  lying  on  either  side,  while  lying  on  the  back 
partially  relieves  it.  The  child  may  grasp  its  throat  every  time 
it  coughs.  The  breath  is  hot,  while  the  mode  of  breathing  has 
nothing  characteristic  ;  it  may  be  labored  and  anxious,  or  quick 
and  superficial,  or  deep,  slow  and  sighing. 

"  The  character  of  the  pulse  is  very  important  for  aeon.  In 
inflammations  it  is  hard,  full,  and  strong.  Restless  sleepless- 
ness, continual  tossing  about,  with  eyes  closed. 

"  The  quantity  of  the  urine  is  greatly  diminished  even  to  re- 
tention. The  urine  is  hot,  dark-red,  brown  and  turbid.  The 
child  is  restless  before  urinating,  and  frequently  cries  during 
the  act. 

"  The  restlessness  of  chamomilla  is  much  more  of  a  nervous, 
passionate  character ;  the  movements  are  rather  of  a  spasmodic 
nature.  The  child  works  itself  into  a  passion,  at  the  height  of 
which  it  will  be  seized  with  a  long-lasting,  exhausting  cough. 
The  cough  will  also  be  dry  (as  in  aeon.),  but  only  so  about  mid- 
night, being  looser  in  the  daytime.  With  the  cough,  we  notice 
a  rattling  of  mucus  in  the  trachea.  The  pulse  is  much  smaller 
and  weaker  than  in  aeon.;  frequently  unequal,  changing  from 
weak  to  tense  and  accelerated.     The  urine  is  also  scanty  and 


574  THE  DISEASES  OF  CHILDREN. 

painful,  but  rather  yellow,  and  its  turbidity  is  of  a  clay  color. 
Cham,  is  of  great  value  in  the  bronchitis  of  teething  children. 

"Another  remedy,  which  I  should  never  like  to  be  without 
in  the  treatment  of  this  affection,  is  cina. 

"  It  is,  so  to  say,  of  a  higher  pitch  than  cham.,  and  simulates 
more  threatening  conditions.  The  child  is  uncontrollable,  but 
deathly  pale  constantly,  whether  quiet,  coughing,  or  crying. 
It  screams  when  approached  or  touched.  The  breathing  is  short, 
at  times  interrupted,  imitating  Cheyne-Stokes  respiration.  The 
cough  is  like  that  of  aeon.,  dry,  short,  hacking,  especially  at 
night,  somet'mes  gagging,  and  the  child  may  seem  to  swallow 
something  immediately  after  coughing.  Unlike  the  two  reme- 
dies above-mentioned,  the  urine  is  copious,  and  passed  fre- 
quently. As  soon  as  the  child  falls  asleep,  it  starts,  screams, 
and  kicks.     Convulsions  may  be  apprehended  at  any  moment. 

"  In  such  apparently  alarming  conditions,  a  few  doses,  even 
a  single  dose,  of  cina,  30th  or  200th,  will  change  the  scream  to 
a  quiet  repose.  The  physical  signs  may  point  \.o  phosphor,  or 
tartarus  emeticus,  but  when  the  above  nervous  symptoms  are 
present,  cina  will  have  to  pave  the  way  for  their  use.  Such 
conditions  are  not  unfrequent  in  nervous  children,  even  when 
free  from  the  intestinal  irritation  of  worms. 

'*  The  most  suitable  remedies  in  bronchitis  are  undoubtedly 
phosphorus  and  antimonium  tartaricum.  The  indications  for 
both  are  too  well  known  to  need  repetition  here.  Still,  in  re- 
gard to  phos.,  I  should  like  to  call  attention  to  a  peculiarity 
diametrically  opposite  to  lachesis.  '  The  cough  and  condition 
of  the  patient  are  always  better  after  sleep.'  This  is  especially 
valuable  when  the  disease  has  become  chronic,  and  a  barky, 
croupy  cough  remains. 

"  Phos.  is  indispensable  in  the  true  capillary  form,  mixed 
with  broncho-pneumonia.  The  pulse  and  temperature  run  high. 
The  pulse  is  full  and  hard,  as  in  aconite,  but  the  time  for  this 
latter  remedy  has  passed.  Also  in  cases  where  prostration  is 
marked,  and  the  pulse  becomes  small,  weak  and  frequent,  phos. 
is  highly  valuable.  It  must  then  be  repeated  according  to  the 
intensity  of  the  symptoms,  every  Jive  to  thirty  minutes,  extend- 
ing the  interval  when  improvement  sets  in. 

"About  ant.  tart.,  I  have  frequently  heard  the  remark,  that 
it  is  indicated  only  when  fair  rales  (in  the  smaller  tubes)  are 
predominant,  while  ipecac  is  said  to  correspond  to  the  coarse 
rattling  (in  the  larger  ones).  Hering  has  it  so  in  his  Condensed 
Materia  Medica,  while  in  his  Guiding  Symptoms  he  heavily 
marks  under  ant.  tart.,  '  Such  rattling  that  it  threatens  to  suffo- 
cate the  child.  Respiration,  with  great  rattling  of  mucus.' 
Again,  we  should  remember  the  characteristic  symptom,  '  When 


CAPILLARY  BRONCHITIS.  575 

the  child  coughs,  there  appears  to  be  a  large  collection  of 
mucus  in  the  bronchial  tubes,'  and  if  we  listen  to  the  chest,  we 
hear  the  snoring,  coarse,  rattling  breathing  all  over  that  region. 

"  The  above  symptoms  all  indicate  ant.  tart.,  and  the  physi- 
cal signs  in  addition,  will  prove  that  this  remedy  is  well  suited 
in  cases  where  the  chest  is  filled  with  mucus  to  the  top  of  the 
throat,  and  consequently  coarse  rales  prevail. 

"  Considering  the  excessive  exhaustion  produced  by  ant. 
tart.,  we  readily  understand  that  it  is  of  high  value  in  impend- 
ing paralysis  of  the  lungs,  characteristic  of  capillary  bronchitis 
mixed  with  broncho-pneumonia. 

"  Drowsiness,  face  deathly  pale,  bloated  or  livid,  eyes  sunken, 
with  blue  margins ;  abdominal,  panting  respiration  ;  unequal, 
intermittent  breathing  during  sleep,  —  all  these  symptoms 
strongly  call  for  ant.  tart. 

*'  The  ant.  sulph.  aur.,  lately  advocated  again  by  old-school 
physicians,  has  been  obsolete  with  them  for  many  years.  Do 
not  ask  them  '  Why  ? ' 

"  Though  its  proving  is  yet  meager,  it  acts  most  charmingly 
in  scrofulous  children  attacked  with  acute  or  chronic  bronchitis, 
with  profuse  accumulation  of  mucus ;  especially  when  they  are 
taciturn,  obstinate,  fretful,  and  peevish.  The  appetite  is  en- 
tirely lost,  breath  foul,  tongue  thickly  coated.  Perhaps  the 
two  atoms  of  sulphur,  which  it  contains,  more  than  the  ant. 
crud.,  give  it  a  deeper  action  on  the  system  generally,  where 
the  latter  drug  seems  to  be  indicated,  but  fails. 

'^Ipecacuanha  is  differentiated  from  ant.  tart,  as  follows: 
First  of  all,  the  bronchial  rales  are  finer  throughout,  and  if 
coarse,  they  are  not  so  constant  and  prominent,  as  in  tart,  emet., 
but  appear  rather  with  deeper  inhalations.  The  cough  of  ipec. 
is  more  spasmodic,  and  the  tendency  to  vomit  is  greater  with 
this  drug.  In  antimony  the  tendency  to  pulmonary  paralysis, 
general  exhaustion,  and  collapse  is  greater,  while  in  ipec,  the 
spasmodic  character  prevails  with  the  prostration. 

"  Many  other  remedies  have  been  successfully  used  by  differ- 
ent physicians  on  special  indications,  as  hepar,  when  the  cough 
is  croupy,  but  when,  as  Prof.  T.  F.  Allen  appropriately  describes 
it,  '  the  sharp  edge  of  the  cough  is  broken  off.'  It  is  rather  a 
choking,  phlegmy  cough.  It  is  frequently  called  for  after  the 
exhibition  of  ant.  tart. 

"  The  keynote  for  lycopodium,  '  the  fanlike  motion  of  the 
alae  nasi,'  is  not  a  simple  rising  and  falling  of  these  parts,  as 
belladonna  and  some  others  have  it,  and  which  has  disappointed 
many ;  but  the  nose  is  widely  dilated,  like  the  end  of  a  trumpet, 
and  then  forcibly  contracted. 

'^ Arsenicum  is  another  remedy  of  high  value  in  capillary 


576  THE  DISEASES  OF  CHILDREN. 

bronchitis.  Excessive  anxiety,  as  expressed  in  the  face,  which 
is  earthy  gray,  sunken,  or  edematous ;  the  child  cannot  find 
rest  anywhere,  changes  continually  from  bed  to  lap  and  vice 
versd ;  burning  heat,  with  great  thirst  for  small  quantities  of 
cold  water ;  these  are  the  well-know  characteristics  which  call 
for  arsen.  and  seldom  in  vain. 

"  With  dulcamara,  chelidonium,  bryonia,  gelsemium,  eupa- 
torium,  rumex,  and  veratrum  viride  I  have  had  little  ex- 
perience. 

"  In  conclusion,  let  me  say  that  there  should  not  be  any 
more  difficulty  in  the  treatment  of  capillary  bronchitis  than  of 
any  other  diseased  condition  ;  that  we  should  not  be  misled  by 
supposed  pathological  conditions,  nor  that  we  should  give  pref- 
erence to  any  drug  recommended  in  the  books  for  such  condi- 
tions. We  must  be  guided  strictly  and  only  by  the  facts 
presented  to  our  trained  senses  and  reason,  and  select  carefully 
from  the  wealth  of  our  materia  medica,  that  drug  which  alone 
will  answer  our  purpose,  though  it  may  never  have  been 
thought  of  in  that  connection  before.  Let  the  homeopathic 
physician  ever  remember  '  The  more  haste  the  less  speed.'  " 


CHAPTER  IX. 

ASTHMA. 

Definition. — Asthma  consists  of  irregular  or  periodic  attacks 
of  paroxysmal  dyspnea,  with  intervals  between  of  entirely  or 
comparatively  free  and  unembarrassed  respiration. 

The  infrequency  of  asthma  among  infants  and  children  in 
this  country  is  doubtless  the  reason  that  nearly  all  American 
text-books  on  diseases  of  children  take  no  notice  of  it.  Day 
is  about  the  only  English  author  who  more  than  mentions  it. 
Goodhart  ignores  it  entirely.  West  devotes  less  than  a  page 
to  it,  while  Underwood,  Churchill,  Steiner  and  Niemeyer  do 
not  even  allude  to  it  as  a  disease  occurring  in  childhood.  It  is 
surprising,  therefore,  to  read  the  statement  of  Hyde  Salter  that 
"more  cases  originate  during  the  first  decade  than  during  any 
other  period  of  life."  He  further  states  that  out  of  225  cases 
(all  ages),  71  dated  back  to  the  first  ten  years  of  life,  and  in  11 
of  the  number,  it  came  on  under  the  age  of  one  year.  West 
confirms  these  observations  and  cites  Lochner,  of  Prague,  and 
Dr.  Politzer,  as  having  also  frequently  met  with  it  in  early  life. 
According  to  our  own  experience,  it  must  be  very  rare,  for  we 
have  never  met  with  more  than  half  a  dozen  cases,  either  at 
the  Half  Orphan  Asylum,  at  the  Dispensary,  or  in  private 
practice. 

It  is  not  a  disease  likely  to  be  often  encountered  in  dispensary 
practice,  for,  according  to  all  authorities  who  make  mention  of 
it,  it  is  more  common  in  the  upper  than  in  the  lower  classes, 
for  reasons  which  will  appear  later  on. 

Etiology. — The  causes  which  are  supposed  to  enter  into  the 
production  of  asthma  are  divided  into  predisposing  and  exciting. 
The  predisposing  causes  are  largely  hereditary.  In  rather  more 
that  two-fifths  of  all  Salter's  cases  he  found  distinct  traces  of 
inheritance,  direct  or  lateral,  near  or  remote.  He  also  found 
the  disease  much  more  prevalent  among  boys  than  girls — the 
proportion  in  sixty-three  cases  being  forty-six  to  seventeen. 
No  satisfactory  solution  of  this  difference  is  given.  Theoretic- 
ally the  figures  ought  to  be  reversed,  for  asthma  is  generally 
regarded  as  one  of  the  many  and  various  manifestations  of 
what  is  called  the  neurotic  temperament,  or  constitution,  which 
reaches  a  higher  development  in  females  than  males.  Among 
D.  C— 37  (577) 


578  THE  DISEASES  OF  CHILDREN. 

the  exciting  causes  are  those  which  act  directly  on  the  lungs, 
such  as  bronchitis,  either  primary  or  secondary  ;  whooping 
cough  and  pneumonia ;  the  presence  of  emphysema  in  the 
lungs,  and  especially  that  collapsed  condition  of  certain  por- 
tions of  the  lungs  known  as  atelectasis,  occurring  from  rachitic 
deformity,  or  from  broncho-pneumonia.  Enlargement  of  the 
bronchial  glands  is  also  mentioned  as  a  cause  of  asthma  from 
pressure  upon  the  pneumogastrics.  Other  exciting  causes  are 
reflex  in  their  nature.  Among  these  are  nasal  polypi  and  irri- 
tation of  the  gastric  nerves  by  worms  or  indigestible  food — 
peptic  asthma.  Another  form  of  the  disease  is  known  as  her- 
petic asthma,  which  arises  from  certain  affections  of  the  skin, 
notably  eczema  and  urticaria. 

West  says  :  "  I  have  never  known  eczema  to  be  very  exten- 
sive and  very  long  continued  without  a  marked  liability  to 
asthma  being  associated  with  it.  It  cannot  be  said,  however, 
that  the  two  conditions  always  alternate,  the  asthma  being 
worse  when  the  cutaneous  affection  is  better ;  but  the  radical 
cure  of  the  eczema  is  usually  followed,  though  often  not  till 
after  the  lapse  of  three  or  four  years,  by  the  cessation  of  the 
liability  to  asthma.  Uremic,  gouty  and  saturnine  subjects  are 
quite  liable  to  asthma.  Trousseau  tells  of  a  boy  of  five  whom 
he  saw  in  well-characterized  fits  of  asthma,  and  who,  two  years 
later,  had  typical  gouty  arthritis,  during  the  continuance  of 
which  he  was  free  from  his  asthma. 

Salter  tells  of  an  adult  who  could  produce  an  attack  at  will 
by  applying  cold  to  the  instep. 

Dr.  Leila  G.  Bedell  has  reported  a  number  of  cases  of  well- 
marked  asthma  which  she  considers  entirely  idiopathic,  that  is 
to  say,  unconnected  with  any  other  disease,  as  measles,  whoop- 
ing cough,  or  bronchitis  ;  but  in  all  of  them  the  neurotic  feature 
was  well  marked.  One  of  them  was  only  affected  with  an  at- 
tack "  when  sitting  from  daylight  through  twilight  into  dark- 
ness." The  attacks  always  occurred  immediately  after  dark  and 
were  preceded  by  continued  gaping.  Another  case  was  al- 
ways preceded  by  continued  sneezing,  as  if  an  acute  coryza 
were  about  to  set  in  ;  while  still  another  has  attacks  following 
a  severe  spell  of  crying.  Dr.  Bedell's  cases  were  all  girls,  her 
experience  being  contrary  to  that  of  Salter  and  others  in  this 
respect.  In  four  of  her  five  cases  the  asthmatic  tendency 
seemed  to  have  descended  from  the  grandmother  on  the 
father  s  side,  and  in  the  fifth  case  from  the  grandfather  on  the 
mother  s  side — the  intervening  generation  in  each  case  having 
shown  no  tendency  whatever  to  asthma. 

In  all  of  the  cases  one  type  prevailed,  viz.,  a  sensitive,  deli- 
cate, nervous  organization.     After   discussing   these   cases  at 


ASTHMA.  579 

length,  Dr.  Bedell  says :  "  Hence,  from  my  standpoint  (regard- 
ing the  sympathetic  system  the  seat  of  the  emotions  rather 
than  the  brain),  I  should  regard  asthma  as  preeminently  a  neu- 
rosis, having  its  origin  in  the  sympathetic ;  and  conclude  that 
the  only  relation  which  the  pneumogastric  sustains  to  the  dis- 
ease, obtains  wholly  from  its  intimate  connection  with  the 
sympathetic  through  the  fibers  arising  from  the  sympathetic 
ganglia  on  the  root  and  on  the  trunk  of  that  nerve.  In  the 
treatment  of  such  cases  the  list  of  remedies  which  I  have  found 
successful  narrows  itself  down  to  three — namely,  gelsemiuni 
30X,  sambucus  6x,  and  ipecac  3X. 

"  In  the  case  of  the  child  whose  attacks  were  always  preceded 
by  crying  spells,  gels.  30X,  was  the  only  remedy  which  ever 
gave  relief." 

In  many  cases  of  asthma,  when  the  habit  is  once  established, 
the  exciting  cause  is  too.  trifling  in  many  instances  to  be  rec- 
ognized. The  attacks  occur  at  all  seasons  of  the  year,  though 
more  frequently  in  spring  and  autumn,  when  colds  are  most 
prevalent.  If  the  attacks  are  not  exceptionally  severe  and  fre- 
quent, there  is  a  strong  probability  of  their  ceasing  about  or 
before  puberty.  In  two  of  our  own  cases,  that  resisted  all  rem- 
edies that  were  brought  to  bear  upon  them,  the  attacks  ceased 
spontaneously,  one  at  the  age  of  eleven,  the  other  at  twelve. 

Pathology. — All  that  is  known  relative  to  the  pathology  of 
asthma  is  summed  up  in  these  words  of  Berkart,  "Asthma, 
therefore,  is  only  one  link  in  a  chain  of  quasi-independent  af- 
fections, which  commences  with  inflammatory  changes  of  the 
pulmonary  tissue,  and  terminates  with  emphysema  or  bron- 
chiectasis." 

The  symptoms  of  asthma  in  children  do  not  differ  from  those 
of  the  adult.  The  attack,  as  a  rule,  comes  on  suddenly.  The 
face  is  pale,  cyanotic  and  anxious.  The  skin  is  moist  and  cool. 
There  is  no  fever.  The  pulse  is  rapid  and  often  irregular.  The 
respiration  is  slow  and  labored,  expiration  being  much  pro- 
longed ;  the  chest  is  fixed  in  the  position  of  full  inspiration, 
with  a  low  diaphragm  ;  percussion-resonance  is  increased  in 
intensity  and  area ;  on  auscultation  the  respiratory  murmur  is 
much  enfeebled  or  absent,  and  sibilant  and  sonorous  rales  are 
heard  everywhere.  The  cough,  if  present,  is  short  and  dry.  If 
the  child  is  old  enough  to  expectorate,  the  paroxysm  is  gener- 
ally terminated  by  the  expulsion  of  a  small  quantity  of  tough, 
viscid  mucus.  The  attacks  usually  end  as  they  came,  the  child 
falling  asleep,  and  awaking  next  morning  as  well  as  usual.  The 
frequency  of  repetition  is  very  variable  and  irregular. 

The  prognosis,  as  above  indicated,  is  usually  good. 

Treatment. — Besides  the  remedies  mentioned  by  Dr.  Bedell, 


580  THE  DISEASES  OF  CHILDREN. 

and  which  are  the  ones  we  have  ourselves  used  with  the  most 
success,  there  are  others  which  may  prove  useful  in  cases  where 
these  have  failed,  or  where  the  indications  point  to  them,  viz., 
cuprum,  veratrum,  aiirum  brom.,  staphysagria.  arsenicum,  bry- 
onia,  and  hyoscyamus. 

EMPHYSEMA. 

The  term  emphysema  is  used  to  denote  an  excess  of  air  in 
the  lungs — either  in  the  distended  cells  of  the  lungs,  constitut- 
ing vesicular  emphysema ;  or  into  the  intercellular  spaces,  con- 
stituting interstitial  emphysema. 

Vesicular  emphysema  is  that  form  in  which  the  air  is  still 
contained  within  the  air  vesicles,  and  is  by  far  the  most  fre- 
quently met  with.  Only  a  few  of  the  air  sacs  may  be  involved, 
the  whole  of  a  lobe,  or  even,  in  extreme  cases,  the  entire  lung. 
The  apices  and  margins  of  the  base  of  the  lungs  are  particularly 
liable  to  be  affected.  In  emphysema  the  lungs  are  increased  in 
size,  while  their  elasticity  is  destroyed.  It  is  not  a  disease  pe- 
culiar to  childhood,  but  may  occur  at  any  age.  As  it  is  often 
encountered  in  early  life,  it  requires  a  brief  description.  It  is 
especially  frequent  in  children  who  are  the  subjects  of  rickets 
and  asthma.  In  some  cases,  however,  it  appears  to  be  congeni- 
tal. In  vesicular  emphysema  the  morbid  anatomy  shows  only 
enlarged  air  vesicles,  with  here  and  there  one  which  has  been 
distended  beyond  the  point  of  rupture,  so  that  two  or  more 
sacs  are  thrown  together.  This,  however,  is  a  rare  accident. 
More  frequently  the  walls  of  the  air  cells  are  simply  distended, 
their  elasticity  destroyed,  and  they  resemble  a  small,  inanimate 
bladder  more  or  less  inflated  with  air.  Atelectasis  is  a  term 
denoting  collapse  of  the  air  cells,  with  the  cell  walls  in  apposi- 
tion ;  emphysema  is  its  direct  opposite.  Sometimes  the  bron- 
chioles or  medium-sized  bronchial  tubes  are  distended,  and  lose 
their  resilency,  which  condition  is  \^noyNn  3iS  bronchiectasis.  This 
is  so  rare  a  condition  as  to  deserve  nothing  more  than  its  bare 
mention  here,  and  the  statement  that  it  has  been  known  to 
occur  as  a  result  of  whooping  cough,  bronchitis  pr  pneumonia. 

In  interstitial  emphysema  (sometimes  called  interlobular),  the 
connective  tissue  which  binds  the  lobules  together  is  infiltrated 
with  air,  which  has  escaped  from  the  ruptured  vesicles,  and 
sometimes  this  is  sufficient  to  raise  the  pleura  from  the  surface 
of  the  lung.  There  are  no  real  tissue  changes  in  emphysema, 
other  than  those  implied  in  the  foregoing  description.  There 
is  no  inflammation,  no  degeneration  of  tissue,  no  catarrh  other 
than  that  which  may  belong  to  the  bronchitis  or  the  whooping 
cough  which  preceded  the  dilatation.  The  cause  of  the  trouble 


EMPHTSEMA.  581 

may  be  indirectly  traceable  to  inopportune  closure  of  the  glot- 
tis. In  pertussis  the  explosive  nature  of  the  cough  produces 
a  greatly  increased  pressure  on  the  delicate  walls  of  the  vesicles, 
and  this  is  added  to,  if,  at  the  moment  of  cough,  the  glottis  is 
closed,  as  it  is  liable  to  be,  in  efforts  at  suppression.  The  re- 
sult is  felt  in  the  air  cells,  which  feel  the  pound  of  the  cough, 
and  are  unable  to  resist  its  force. 

If  the  opening  through  which  air  has  escaped  is  small  or  soon 
closed,  the  misplaced  air  is  readily  absorbed,  and  but  little 
damage  is  done  ;  but  if  air  continues  to  pass  out,  it  may  find 
its  way  between  the  lung  and  the  pleura  along  the  trachea,  or 
sheath  of  the  vessels,  and  distend  the  subcutaneous  cellular 
tissue.  The  rupture  of  air  cells  may  be  due  to  external  injury 
or  violence  ;  or  to  forced  respiration  into  the  air  passages  of  an 
asphyxiated  infant. 

It  is  more  common  in  bronchitis  and  whooping  cough  than  in 
pneumonia  or  phthisis.  The  disease  is  said  to  produce  hyper- 
trophy of  the  right  heart  and  cerebral  congestion. 

Symptoms. — The  chief  symptoms  are  shortness  and  difficulty 
of  breathing.  This  is  increased  by  any  physical  exertion,  such 
as  walking  fast  or  ascending  stairs.  At  first  this  is  only  felt 
when  some  unusual  exertion  is  made,  but  as  the  disease  ad- 
vances, the  breathing  becomes  permanently  accelerated  and 
even  panting  when  the  patient  is  sitting  still.  In  mild  cases, 
even  a  true  emphysema  of  short  duration  may  present  no  recog- 
nizable symptoms  during  life.  Children  suffering  from  emphy- 
sema, do  not,  as  a  rule,  suffer  the  same  amount  of  distress  in 
consequence,  that  adults  do.  The  sputum  is  sometimes  tinged 
with  blood,  from  ruptured  capillaries  in  the  over-distended  air 
cells.  The  face  is  apt  to  be  dusky,  and  in  long-standing  cases, 
cyanotic.  The  nostrils  are  dilated,  the  voice  is  weak,  and  the 
cough  feeble.  The  finger  tips  are  cold  and  blue.  Headache 
and  drowsiness  are  usually  experienced.  The  abdomen  is  dis- 
tended and  as  a  result  of  the  disease,  the  liver  and  spleen  be- 
come increased  in  size.     Emaciation  is  frequently  noticed. 

In  cases  attended  with  dropsy,  tricuspid  regurgitation  is  pres- 
ent. The  entire  thorax  is  misshapen,  the  upper  part  being 
enlarged,  giving  it  a  barrel  shape.  The  ribs  lose  their  obliquity, 
and  their  anterior  extremities  are  drawn  upwards. 

The  respiration  is  peculiar  and  characteristic.  The  upper 
part  of  the  chest  is  nearly  fixed,  and  the  diaphragm  appears 
passive.  The  inspiration  is  short  and  hurried,  from  the  dimin- 
ished expansion  of  the  chest,  and  the  expiration  is  wheezy  and 
prolonged.  Spasmodic  fits  of  coughing  are  common,  especially 
if  the  bronchial  tubes  are  loaded  with  mucus.  In  conversation, 
the  child  waits  to  get  breath  ;  if  its  answers  are  required  quickly. 


582  THE  DISEASES  OF  CHILDREN. 

it  stops  frequently  in  the  midst  of  a  sentence  to  get  fresh  breath. 
When  emphysema  is  complicated  with  organic  disease  of  the 
heart,  or  with  confirmed  asthma,  the  prognosis  is  bad.  The 
disease  is  probably  irremediable.  But  when  it  occurs  as  the 
accompaniment  of  whooping  cough,  it  will  gradually  pass  away 
with  the  disorder,  and  the  child  may  grow  up  without  any  sign 
of  ever  having  suffered  from  it. 

This  observation  of  Day's  we  have  repeatedly  confirmed. 
Auscultation  and  percussion  yield  no  satisfactory  results  in  this 
disease. 

Treatment. — From  what  has  been  said  relative  to  the  cause 
and  nature  of  this  affection,  but  little  good  is  to  be  expected 
from  drugs  administered  with  reference  to  direct  results.  But 
great  good  may  be  anticipated  from  indirect  treatment,  by 
which  we  mean,  treatment  addressed  to  the  causes  which  have 
been  active  in  the  production  of  the  diseased  condition. 

The  patient  here,  as  everywhere,  needs  the  medicine  and  not 
the  disease.  The  cough  must  be  controlled — hence  remedies 
addressed  to  the  cough,  are  of  first  moment.  Then  remedies 
should  be  addressed  to  the  general  cachexia.  The  appetite 
should  be  improved ;  the  general  health  improved ;  perhaps  a 
change  of  air  may  be  advisable ;  pulmonary  gymnastics  and 
massage  of  the  chest  are  advised.  Every  precaution  should  be 
taken  to  prevent  an  access  of  fresh  colds,  and  an  aggravation 
of  the  cough  already  present. 


CHAPTER  X. 

atelectasis  (collapse  of  lung ;   fetal  condition  of 

lung). 

Two  forms  of  atelectasis  are  recognized,  namely,  congenital 
and  acquired.  In  the  former  variety  some  portion  of  the  lung, 
more  or  less,  remains  unexpanded  after  birth,  and  in  these  por- 
tions the  fetal  condition  is  maintained  for  hours,  or  in  some 
cases,  for  weeks  and  months.  In  the  acquired  variety,  owing 
to  some  obstruction  to  the  respiratory  act,  certain  portions  of 
lung — sometimes  an  entire  lobe — collapse,  and  being  impervious 
to  air,  the  same  fetal  condition,  as  in  the  former  case,  is  pres- 
ent. The  congenital  variety  is  usually  to  be  regarded  as  one 
of  the  accidents  of  birth.  In  some  cases  it  is  due  to  protracted 
labor,  to  breech  presentation,  to  prolapse  of  the  cord,  etc.  In 
cases  in  which  no  respiratory  act  has  taken  place,  of  course  the 
whole  of  both  lungs  remains  airless,  and  there  is  general  ate- 
lectasis. In  the  acquired  form,  the  extent  of  collapse  varies 
from  a  small  area  to  an  entire  lobe,  or  lobes.  Various  causes 
operate  to  bring  about  this  condition.  It  is  a  very  common 
one  in  infants  prematurely  born,  and  is  due  in  such  cases  to  the 
inherent  weakness  of  the  child  ;  it  lacks  the  strength  to  take  a 
vigorous  inspiration,  and  the  lungs  consequently  remain  unex- 
panded. Later  on,  still  owing  to  an  excessively  feeble  state  of 
the  organism,  the  air  is  gradually  expelled  from  the  air  cells, 
but  there  is  not  strength  enough  to  refill  them,  and  collapse  of 
the  cell  takes  place.  Again,  an  infant  affected  with  rickets,  in 
whom  the  bones  are  soft  and  yielding  to  atmospheric  pressure, 
acquires  atelectasis  from  compression  of  the  lungs.  Whooping 
cough,  bronchitis  and  broncho-pneumonia  are  very  often  fore- 
runners of  this  disease,  and  it  frequently  comes  on  suddenly 
and  without  warning. 

The  acquired  variety  of  atelectasis  is  not  confined  to  infancy, 
but  is  common  to  all  ages.  It  is  most  frequently  met  with, 
however,  at  the  two  extremes  of  life — infancy  and  old  age. 

It  is  stated  that  the  portions  of  lung  most  apt  to  be  affected 
by  pulmonary  collapse  are  the  interior  margins  of  the  lungs,  the 
edges  of  the  lower  lobes,  and  the  middle  lobe  of  the  right  lung. 
In    any  event,  whether   the  morbid  condition    is   congenital 

(583) 


584  THE  DISEASES  OF  CHILDREN. 

or  acquired,  the  results  are  the  same.  The  affected  portion  of 
lung  is  unexpanded,  collapsed,  airless. 

Etiology. — In  addition  to  the  causes  already  noted  for  im- 
perfect or  non-expansion  of  the  lungs  at  birth,  there  are  various 
others  mentioned  by  authorities,  such  as  imperfect  develop- 
ment of  the  respiratory  nerve  centers  of  the  fetus,  which  then 
do  not  respond  to  the  want  of  oxygen,  and  no  respiratory  act 
is  attempted.  In  such  cases  the  child  is  "  still-born."  In  some 
cases,  as  in  premature  detachment  of  the  placenta,  or  pla- 
centa previa,  there  is  a  sudden  interruption  to  the  supply 
of  oxygen  from  the  maternal  blood,  which  excites  violent 
efforts  on  the  part  of  the  child,  which  only  result  in  inhaling 
blood,  mucus,  meconium  or  liquor  amnii,  which,  being  drawn 
into  the  larynx  or  trachea,  produce  suffocation  and  pulmonary 
collapse. 

A  very  common  cause  of  acquired  atelectasis  in  infants  is  a 
firm  plug  of  mucus  acting  as  a  ball-valve,  preventing  air  from 
entering  the  air  vesicle,  while  it  does  not  prevent  the  contained 
air  from  escaping.  In  other  cases  the  bronchiole  leading  to  the 
alveoli  is  occluded  by  swelling  or  mucus,  and  eventually  the  air 
contained  in  the  vesicle  is  absorbed  and  the  cell  collapses. 
West  has  pointed  out  the  fact  that  collapse  of  the  lung  may 
occur  independently  of  any  affection  of  the  air  passages.  He 
cites  an  instance  of  this  kind  in  which  the  patient,  a  little  girl 
five  months  old,  died  greatly  exhausted  from  diarrhea.  There 
was  extensive  atelectasis  of  the  right  lung,  but  the  bronchia 
were  pale,  and  contained  no  secretions. 

Collapsed  portions  of  lung  occupy  less  space  than  normal 
lung  tissue,  and  sink  below  the  general  level  of  lung  surface. 
As  the  collapsed  areas  are  generally  small  in  size,  it  gives  the 
affected  lung  an  irregular  outline.  An  atelectalic  lung  is  of 
leaden  hue,  and  when  cut,  a  clear  or  bloody  fluid  exudes.  It  is 
firm  to  the  touch,  or  perhaps  somewhat  sodden  in  consistence, 
like  liver  or  spleen.  From  its  resemblance  to  ordinary  flesh,  it 
is  said  to  be  in  a  condition  of  carnification. 

Symptoms. — When  imperfect  expansion  of  the  lung  exists 
from  birth,  the  physician  in  attendance,  upon  that  event,  need 
have  no  difficulty  in  the  recognition  of  the  trouble.  The  heart- 
beat is  feeble  and  irregular,  the  cry  is  faint  or  almost  inaudible, 
there  are  no  voluntary  movements  of  the  limbs,  the  respiratory 
efforts  are  made  only  at  long  intervals,  and  then  are  weak  and 
desultory  gasps ;  the  color  of  the  child,  instead  of  being  dusky 
red,  is  pale,  leaden  or  cyanotic.  If  an  occasional  feeble  effort 
to  breathe  is  made,  it  is  accompanied  with  a  moist,  rattling 
sound.  The  infant  shows  great  weakness ;  the  limbs  hang  limp 
and  motionless  ;  the  eyes  are  closed  and  the  pupils  dull.     The 


A  TEL ECTA SIS.  585 

lips  have  a  bluish  tint.  The  majority  of  children  born  in  this 
condition  quickly  die,  although  they  may  live  on  for  hours  or 
days.  Under  favorable  circumstances,  the  respiratory  efforts 
become  more  effective,  and  are  closer  together.  Finally,  a 
powerful  inspiration  is  effected,  the  face  loses  its  leaden  hue, 
and  takes  on  a  red  or  natural  pink  color,  the  child  utters  a  loud 
cry,  and  the  pulsation  of  the  heart  becomes  normal  in  rhythm 
and  volume. 

In  acquired  atelectasis,  the  symptoms  are  similar,  but  less 
pronounced.  It  occurs  most  often  in  the  early  period  of  life, 
and  in  delicate  subjects,  who  are  suffering  from  whooping 
cough,  bronchitis,  or  some  wasting  disease,  like  diarrhea.  The 
symptoms  are  referable  to  the  respiratory  function,  and  are 
mild  or  severe,  according  to  the  amount  of  lung  tissue  involved. 
The  breathing  is  hurried  and  shallow — the  inspiration  being 
slower  and  more  difficult  than  the  expiration.  The  pulse  is 
quickened  and  its  volume  is  diminished  in  direct  proportion  to 
the  amount  of  consolidation.  The  color  of  the  skin  is  dark- 
ened, sometimes  to  the  extent  of  lividity.  The  elastic  chest 
walls,  over  the  portion  of  affected  lung,  yield  to  atmospheric 
pressure,  and  are  sunken  as  compared  to  the  condition  over 
other  portions  of  the  chest,  where  the  lungs  are  doing  compen- 
satory work,  and  here  there  may  be  bulging  of  intercostal 
spaces  from  over-inflation  of  the  uncollapsed  vesicles.  Emphy- 
sema, however,  is  not  usually  associated  with  atelectasis. 

In  well-marked  cases  there  are  evidences  of  more  or  less  con- 
solidation or  solidification  of  the  lungs,  which  for  a  long  time 
led  this  condition  to  be  confounded  with  pneumonia. 

The  dullness  on  percussion  is  usually  slight,  unless  there  be 
associated  with  the  collapse  an  abundant  pleuritic  effusion  or 
pneumothorax.  There  is  no  inflammatory  condition  attached 
to  atelectasis  pure  and  simple,  consequently  there  is  no  increase 
of  bodily  temperature,  except  as  it  is  associated  with  other 
febrile  maladies.  The  general  state  is  one  of  prostration  and 
great  depression,  and  after  a  period  varying  from  days  to  weeks 
or  months,  the  child  generally  dies  from  exhaustion. 

Treatment. — In  congenital  atelectasis  every  effort  should  be 
made  to  effect  a  full  inflation  of  the  lungs. 

This  should  be  attempted  by  means  of  artificially  forcing  air 
into  the  lungs ;  by  using  the  Marshall  Hall  method  of  resusci- 
tation ;  massage  of  the  chest,  and  by  alternately  sousing  the 
child  into  hot  and  cold  water.  A  draught  of  cold  air  should  be 
allowed  to  strike  the  bare  cutaneous  surface,  which  tends  to 
arouse  the  dormant  respiratory  nerve.  In  some  cases,  where 
there  has  been  no  special  delay  in  the  labor,  simply  blowing 
in  the  child's  face,  or  slapping  the  buttocks  with  a  towel  wet  in 


586  THE  DISEASES  OF  CHILDREN. 

cold  water,  is  sufficient  to  excite  a  deep  inspiration  and  bring 
forth  a  satisfactory  cry. 

Dr.  Busy  succeeded  in  restoring  life  in  cases  of  this  kind  in 
two  instances  after  all  other  means  had  been  tried,  by  what  is 
known  as  the  Silvester  method  of  resuscitation  in  drowning  cases. 
This  method  consists  in  laying  the  child  upon  its  back,  while 
both  arms  are  slowly  and  simultaneously  raised  towards  and 
alongside  the  head,  and  then  replaced  and  pressed  against  the 
sides  of  the  chest  to  expel  the  air  from  the  lungs.  Dr.  Francis 
Minot,  in  Keating's  Cyclopedia,  thus  describes  a  method  sug- 
gested by  Schultz,  and  which  he  indorses  as  having  proven  ef- 
ficient in  his  hands  :  "  The  child  being  laid  on  its  back,  with  its 
head  toward  the  operator,  is  grasped  by  the  hands  applied  to 
its  chest  and  shoulders  in  such  a  way  that  the  head  falls  back- 
ward, the  face  towards  the  knees  of  the  operator,  while  the 
belly  and  legs  hang  down  in  front.  The  weight  of  the  head  in 
one  direction  and  of  the  rest  of  the  body  in  the  other,  causes 
an  enlargement  of  the  chest  by  traction,  with  depression  of  the 
diaphragm,  and  promotes  inspiration.  The  operator  then  swings 
the  child  quickly  upward,  reversing  its  position  so  that  the 
head  is  flexed  upon  the  chest,  while  the  trunk  and  legs  fall 
downward  and  towards  the  face,  thus  compressing  the  chest 
and  expelling  the  air." 

Faradization  has  been  used  successfully  in  some  cases, 
but  in  our  own  hands  it  has,  for  some  reason,  always  failed. 
It  should  be  applied  with  care,  if  at  all,  and  only  sufficient 
strength  of  current  to  incite  respiratory  effort.  In  acquired 
atelectasis,  the  main  indications  are  to  overcome  the  debility 
and  exhaustion  which  are  always  present,  and  also  the  diseased 
condition  that  has  preceded  the  pulmonary  collapse.  Change 
of  air,  removal  of  the  patient  to  some  elevated  region,  where 
free  ventilation  and  stimulating  atmosphere  can  be  had ;  good, 
nourishing  food,  and  the  judicious  use  of  stimulants  will  often 
prove  beneficial. 

Deep  breathing  and  vocal  gymnastics  are  useful ;  the  patient 
should  be  encouraged  from  time  to  time  to  take  a  deep  and 
forcible  breath,  with  a  view  of  expanding  the  collapsed  por- 
tions of  the  lungs.  Sponging  the  body  with  cool  or  cold  water 
is  useful,  accompanied  with  brisk  friction  with  the  hands  over 
the  entire  body.  The  internal  treatment  by  means  of  drugs,  is 
of  little  use,  except  in  the  acquired  variety.  Here  the  reme- 
dies most  applicable  will  be  those  already  mentioned  under  the 
head  of  capillary  bronchitis  and  those  suggested  in  connection 
with  broncho-pneumonia.  Dr.  Ludlam  relates  a  case  present- 
ing sudden  and  alarming  symptoms  of  collapse  of  the  air  cells, 
following  an  attack  of  bronchitis,  in  a  boy  ten  days  old.     After 


A  TELE  C  TA  S/S.  587 

trying  other  remedies  with  little  or  no  effect,  a  grain  of  tartar 
emetic  2x  trit.  was  put  in  a  third  of  a  glass  of  water,  and  doses 
of  it  given  at  short  intervals.  The  result  was  almost  instan- 
taneous relief,  and  the  child  recovered.  Dr.  L.  expresses  the 
belief  that  antimonium  tartaricum  is  practically  and  patholog- 
ically specific  for  post-natal  collapse  of  the  air  cells.  Nitro-glycer- 
in  3x,  in  weak  solution,  should  be  a  valuable  remedy  in  this 
condition,  from  its  powerful  stimulating  properties. 

When  the  collapsed  state  is  consequent  on  pressure  from  dis- 
tension of  the  pleural  cavity,  the  pleuritic  affection  itself  must 
be  attended  to  before  any  expectations  or  hope  need  be  enter- 
tained of  compressed  pulmonary  tissue  resuming  its  normal 
condition  and  function. 


CHAPTER  XI. 

PULMONARY  PHTHISIS. 

Phthisis  may  be  defined  to  be  that  form  of  tuberculosis 
which  principally  affects  the  pulmonary  tissues.  It  is  also  fre- 
quently referred  to  as  acute  pulmonary  consumption.  In  our 
chapter  on  Tuberculosis,  we  endeavored  to  draw  a  distinction 
between  general  tuberculosis,  in  which  caseous  nodules  were 
found  widely  disseminated  throughout  the  glandular  structures,^ 
and  that  form  of  the  same  pathological  process,  which  is  man- 
ifested when  the  lungs  are  assailed.  It  is  no  longer  necessary 
to  discuss  the  question  whether  tuberculosis  and  phthisis  are 
identical.  Their  identity  is  now  almost  universally  admitted. 
When  tuberculosis  affects  the  lungs,  however,  we  have  a  differ, 
ent  train  of  symptoms;  the  disease  runs  a  shorter  and  some- 
what different  course,  and  the  practice  is  a  proper  one  to  give 
it  special  consideration.  As  regards  the  age  among  children 
when  pulmonary  phthisis  is  most  apt  to  show  itself,  there  is 
much  diversity  of  opinion.  According  to  Portal,  it  may  be 
congenital.  Trousseau  observed  it  quite  often  in  the  first  years 
of  life,  while  Papavoine  asserts  that  it  is  frequent  only  between 
four  and  five  years  of  age.  James  Clark  found  it  frequently 
after  the  second  year,  while  others  deem  its  occurrence  before 
the  age  of  five  or  six  as  rare. 

According  to  Baginsky,  eight  per  cent,  of  all  cases  of  pul- 
monary tuberculosis  are  met  with  prior  to  the  tenth  year. 

About  all  that  need  be  said  under  the  head  of  etiology  of 
phthisis  has  been  said  when  speaking  of  acute  tuberculosis. 

It  is  by  no  means  certain  that  the  disease  is  transmitted  di- 
rectly from  parent  to  child.  It  is  more  probable  that  heredity 
begins  and  ends  with  "  the  propagation  of  a  peculiar  debility 
or  inefficiency  of  either  the  whole  organism,  or  special  organs, 
which  deprives  the  individual  of  its  power  to  resist  injurious  in- 
fluences or  deleterious  invasions."  There  is  unquestionably  an 
inherited  predisposition  to  pulmonary  disease,  which  is  some- 
times very  early  noticeable,  but  in  more  cases  is  only  manifested 
as  the  child  approaches  maturity.  Then  we  observe  **  the  rela- 
tively great  height  of  the  body  as  compared  with  its  weight, 
the  thin  bones  and  muscles,  transparent  and  delicate  skin,  scanty 
subcutaneous  tissue,  the  extensive  nets  of  superficial  veins,  the 
(588) 


PULMONARY  PHTHISIS.  589 

flushed  or  pale  cheek,  pale  mucous  membranes,  flat  chest,  with 
short  sterno-vertebral  diameter,  large  intercostal  spaces,  short- 
ness of  costal  cartilage,  either  congenital  or  resulting  from 
premature  ossification,  the  marked  depth  of  the  supra-  and  intra- 
clavicular  fossae,  the  prominent  scapula,  the  clubbed  finger 
ends,  and  the  feeble  heart." 

The  phthisical  conformation  in  typical  cases  has  been  spoken 
of  by  nearly  all  authors,  ancient  and  modern,  and  yet  it  is  not 
always  safe  to  predicate  a  diagnosis  on  mere  appearances.  We 
are  apt  to  be  frequently  deceived.  It  would  often  puzzle  a 
close  observer  to  distinguish  a  rheumatic  from  a  tuberculous 
subject.  Two  types  are  met  with  that  are  quite  opposite,  and 
yet  both  suggestive.  One  is  the  pretty  and  intelligent  child, 
with  well-formed  but  light  skeleton,  soft  hair,  long  eyelashes, 
peach-like  skin,  good  nails  and  teeth  and  long  fingers.  Then 
there  is  another  type  of  coarser  grain,  the  pale,  sallow,  stunted, 
thick-skinned  and  ill-favored  child  who  goes  the  same  way,  but 
by  a  somewhat  modified  route.  The  shape  of  the  chest  is 
sometimes  quite  characteristic.  Heilier  describes  three  typical 
forms:  (i)  the  long,  circular  chest;  (2)  the  long  chest  with 
narrow  antero-posterior  diameter  ;  (3)  the  long,  pigeon-breasted 
chest. 

In  a  general  way  the  tubercular  chest  may  be  said  to  be  small, 
with  the  apices  contracted. 

In  children  the  apices  of  the  lungs  do  not  exhibit  signs  of 
the  initial  lesion  in  phthisis  nearly  so  often  as  is  the  case  with 
adults.  The  tuberculous  infiltration  is  more  disseminated 
through  the  pulmonary  tissues,  and  disease  foci  are  quite  as 
apt  to  be  found  at  the  base  of  the  lung,  or  in  the  lower  lobes,  as 
at  the  apices.  This  is  accounted  for  by  the  fact  that  in  chil- 
dren a  bronchitis  or  a  pneumonia,  affecting  by  preference  the 
lower  parts  of  the  respiratory  field,  is  commonly  the  precursor 
of  the  tubercular  disease.  Then  again,  the  lungs  of  phthisical 
children  do  not  show  those  cavities  that  are  so  frequently  found 
in  adults.  The  disease  runs  a  more  acute  course,  and  before 
cavitation  of  the  lungs  has  advanced  to  any  great  extent,  the 
disease  has  taken  a  change  of  venue  to  the  meninges  of  the 
brain  or  to  the  mesenteric  glands  of  the  abdomen. 

Symptoms. — Without  discussing  at  length  the  varieties  of 
pulmonary  phthisis,  it  may  be  said  that  in  many  respects  the 
symptoms  do  not  materially  vary  in  childhood  from  those  ob- 
served in  mature  life.  Still,  there  are  some  essential  differences, 
which  will  be  apparent  as  we  proceed.  In  the  early  stages  of 
the  disease,  the  symptoms  are  often  quite  obscure.  The  cough 
may  be  short  and  hard,  dry  and  hacking,  or  loose  and  easy.  It 
is  often  so  trifling  as  to  be  overlooked.     The  child  is  pale  and 


590  THE  DISEASES  OF  CHILDREN. 

thin,  with  a  capricious  appetite.  The  bowels  are  irregular  and 
suggestive  of  worms.  These  derangements  are  apt  to  receive 
little  attention,  being  regarded  as  temporary  and  inconse- 
quential. 

If  a  number  of  careful  examinations  are  made,  however,  it 
will  be  found  that  the  evening  temperature  is  raised,  with  a 
remission  in  the  morning,  which  may  be  so  intense  that  the 
temperature  is  normal  or  subnormal.  The  skin  is  flabby,  waxy, 
yellowish  or  covered  with  pityriasis.  In  infants  the  voice  is 
thin,  and  the  cry  is  low  or  inaudible. 

The  languor,  weakness  and  general  debility  are  marked  and 
progressive.  The  physical  signs,  especially  in  the  early  stages 
of  the  disease,  are  usually  very  ambiguous.  The  signs  are  sub- 
ject to  such  variation,  that  only  a  frequent  repetition  of  exam- 
inations will  enable  one  to  confirm  a  positive  diagnosis.  There 
is  a  lack  of  constancy  in  the  symptoms,  which  is  more  marked 
when  the  disease  begins  at  the  root  of  the  lungs,  because  for 
some  time  it  will  be  covered  by  vesicular  structure,  which  will 
obscure  auscultation  and  percussion  and  confuse  the  data  upon 
which  alone  precision  can  be  based. 

Perspiration,  which  is  so  constant  a  symptom  in  the  adult, 
and  which  is  so  exhausting,  is  equally  as  frequent  and  intense 
in  children.  It  usually  begins  about  midnight,  or  soon  after, 
and  increases  the  tendency  to  emaciation.  Respiration  is  more 
rapid  than  normal,  and  is  superficial  in  character.  The  disease 
is  well  advanced,  as  a  rule,  before  auscultation  and  percussion 
reveal  any  serious  changes  in  the  lungs.  In  some  cases,  there 
are  one  or  more  areas  of  dullness,  but  this  is  by  no  means 
pathognomonic,  for  such  areas  may  come  from  more  interstitial- 
inflammatory  hyperplasia,  or  from  collapse  of  small  portions  of 
lung.  Slight  cavernous  breathing  may  be  present  from  dilata- 
tion of  a  bronchus,  as  well  as  from  a  small  phthisical  cavity. 
When  cavernous  breathing  arises  thus  from  a  dilated  bronchus, 
it  is  more  permanent  than  when  produced  by  a  small  cavity, 
which  may  fill  up  with  mucus  or  pus,  in  which  case  this  charac- 
teristic sound  may  disappear.  Hemorrhages  from  the  lungs  are 
rare  in  children,  more  rare,  indeed,  in  phthisis  than  in  whoop- 
ing cough.  In  the  latter  affection  some  spitting  of  blood  is 
not  infrequent,  and  serious  consequences  may  arise  from  blood 
coagulating  in  the  finest  bronchioles,  causing  local  collapse  of 
the  lung,  and  broncho-pneumonia  in  consequence. 

Complication. — Pleurisy,  usually  of  fibrinous  character  and  of 
localized  extent,  is  a  very  common  and  painful  complication. 
It  may  occur  early  in  the  disease,  especially  if  bronchitis  or 
broncho-pneumonia  has  preceded.  In  other  cases  it  may  not 
appear  until  the  disease  has  made  considerable  progress. 


PULMONARY  PHTHISIS.  591 

In  children  in  whom  the  disease  is  running  a  chronic  course, 
we  have  the  same  comphcations  as  are  witnessed  in  adults,  idz.: 
lardaceous  disease  of  the  viscera,  fatty  liver,  tabes  mesenterica, 
and  intestinal  or  laryngeal  ulceration. 

Death  occurs  in  most  cases  in  very  young  children,  through 
the  outbreak  of  a  general  or  acute  tuberculosis,  and  the  ex- 
tension of  the  disease  to  the  brain  and  its  membranes. 

Prognosis. — It  is  doubtless  true  that  pulmonary  phthisis  is  in 
many  cases  susceptible  of  amelioration.  It  is  also  undoubtedly 
true  that  under  favorable  circumstances,  and  in  cases  where  the 
disease  has  made  but  little  progress,  recovery  is  sometimes  pos- 
sible. Favorable  cases  are  those  in  which  heredity  cuts  but  a 
small  figure,  or  no  figure  at  all,  and  where  the  disease  is  super- 
induced by  a  primary  disease,  such  as  whooping  cough,  pneu- 
monia, bronchitis,  or  a  limited  condition  of  atelectasis.  Some 
cases  of  pulmonary  phthisis  must  recover,  htcdiUSQ  post-mortem 
examination  of  the  lungs  of  children  and  adults,  dead  of  some 
other  disease,  often  reveals  the  cicatrices  of  old  inflammations 
and  cavities  of  unmistakable  tuberculous  origin.  It  is  no  un- 
common thing  to  find  in  necropsies  chalky  concretions,  calcare- 
ous deposits,  and  old  adhesions  which  mark  the  site  of  former 
specific  disease,  from  which  the  patient  has  recovered.  It  may 
be  accepted,  therefore,  as  certain  that  tubercular  disease  is 
sometimes  amenable  to  treatment. 

At  the  same  time,  it  must  be  remembered  that  cases  may 
ameliorate  for  a  time,  and  then  suddenly  develop  meningitis  or 
general  tuberculosis,  with  fatal  results. 

It  must  be  borne  in  mind,  also,  that  if  cases  do  not  show  any 
tendency  to  improvement,  the  course  of  the  disease  in  children 
is  habitually  shorter  than  it  is  in  adults. 

Treatment. — The  successful  treatment  of  pulmonary  phthisis 
must  necessarily  be  largely  hygienic  and  circuitous. 

There  are  no  drugs  having  the  power  to  directly  arrest  the 
progress  of  tubercle.  Good  feeding  and  good  air  are  primarily 
essential.  And  just  here  we  are  met  oftentimes  with  unsur- 
mountable  obstacles.  The  appetite  is  capricious,  or  the 
stomach  intolerant  of  such  articles  of  food  as  the  requirements 
demand.  Vomiting  is  easily  excited,  and  fats  which  are  neces- 
sary to  antagonize  waste  cannot  be  taken.  A  diet  rich  in  fats 
is  very  desirable,  if  it  can  be  borne.  These  children  should  be 
encouraged  to  eat  plentifully  of  milk,  cream  and  fresh  eggs. 
Rare  beef  and  mutton,  or  the  expressed  juice  of  either,  is  \&xy 
rich  in  nutrition.  Stimulants  in  small  quantities  are  of  unques- 
tioned value.  Every  attention  must  be  given  to  the  general 
health  ;  the  tendency  to  diarrheas  must  be  carefully  guarded, 
and  plenty  of  fresh  air  is  an  absolute  necessity.     The  rooms  in 


592  THE  DISEASES  OF  CHILDREN. 

which  the  child  lives  and  sleeps  should  be  well  ventilated.  If 
the  mother  is  not  perfectly  healthy  and  a  good  nurser,  a  wet 
nurse  should  be  secured,  or  in  lieu  of  this,  suitable  artificial  food 
should  be  substituted.  One  of  the  best  foods  for  these  cases 
is  composed  partly  of  proteinol,  which  is  a  compound  of  pure 
beef  fat,  eggs  and  sherry  wine. 

Cod-liver  oil  in  some  form  has  a  well-earned  reputation  in 
the  treatment  of  phthisis.  There  are  preparations  now  in  the 
market  in  which  the  taste  of  the  oil  is  so  disguised  that  the 
most  sensitive  palate  can  scarcely  detect  it.  Combined  with  malt, 
or  maltine,  of  which  there  are  numerous  brands,  it  will  answer  a 
good  purpose  if  not  too  laxative. 

There  are  cod-liver  oil  biscuits  in  which  the  taste  of  the  oil 
is  elegantly  concealed  ;  and  almondized  oil,  and  capsules,  any 
of  which  is  well  calculated  to  overcome  fastidiousness.  But 
infants  and  young  children  do  not  usually  object  to  the  clear 
oil,  if  well  refined  and  purej  and  the  nearer  we  get  to  the  crude 
oil,  other  things  being  equal,  the  better. 

But  the  crowded  city  or  town  is  no  place  for  a  child  afflicted 
with  tuberculosis.  A  place  in  the  country  should  be  chosen 
where  the  air  is  dry  and  plenty  of  opportunity  can  be  had  for 
out-of-door  living.  The  skin  should  be  kept  in  an  active  and 
healthy  condition  by  frequent  sponge  baths,  combined  with 
brisk  frictions  (massage).  When  gastric  catarrh  is  present,  it 
should  receive  immediate  and  persistent  attention.  It  is 
thought  by  many  that  inhalations  of  turpentine,  eucalyptol, 
menthol,  tar,  etc.,  are  of  benefit.  We  have  never  been  able  to 
satisfy  ourselves  of  any  permanent  good  from  them,  although 
they  sometimes  seem  to  produce  temporary  amelioration. 
Even  this  is  something.  Sometimes  the  cough  may  be  allayed 
somewhat  by  simple  means  in  addition  to  the  homeopathic 
remedy.  Thus,  sipping  from  time  to  time  a  little  glycerin 
and  water,  or  glycerin,  rock  candy,  and  dilute  whisky,  gum- 
arabic  water,  Iceland-moss  tea,  flax-seed  tea,  made  quite  sweet 
with  rock  candy  ;  or  letting  a  little  vaseline  or  cocoa  butter  dis- 
solve in  the  mouth. 

For  night  sweats,  sponging  the  body  over  with  vinegar  and 
water,  or  what  is  more  pleasant,  acetic  or  sulphuric  acid  with 
cologne  and  water,  at  bed-time,  for  several  nights  in  succession 
has  often  a  happy  effect.  Small  doses  of  picrotoxiyi  3X  at  bed- 
time, is  strictly  homeopathic.  Sometimes  with  older  children 
a  tumblerful  of  milk  or  buttermilk  works  well. 

Medicinal  Treatment . — To  give  the  indications  for  all  the 
remedies  which  may  be  of  use  in  this  affection,  in  all  of  its  stages 
and  phases,  is  out  of  the  question.  The  list  of  the  leading  ones 
is  all  that  space  will  permit.     For  others,  the  reader  is  referred 


PULMONAR2'  PHTHISIS.  593 

to  pages  512,  514,  where  an  extensive  repertory  of  cough  reme- 
dies will  be  found,  and  also  to  the  chapter  on  Pneumonia  and 
Bronchitis. 

Antimonium  tart. — Cough  short,  shrill,  loose,  and  rattling, 
aggravated  at  night  and  followed  by  nausea,  vomiting  and 
dyspnea ;  excessive  restlessness ;  prostration  ;  chest  full  of  loud, 
rattling  mucus. 

Arscnicuvi.—Gre.2l  emaciation,  weakness  and  prostration; 
intense  burning  pains  in  stomach,  with  intense  nausea  and 
vomiting ;  excessive  thirst,  drinks  often,  but  little  at  a  time  ; 
breathing  very  difficult ;  diarrhea,  stools  dark  and  acid,  ex- 
coriating anus  and  nates;  burning,  shooting  stitches  in  lungs. 

Belladonna. — Intense  congestion  of  head,  with  violent,  throb- 
bing headache ;  face  red  and  hot ;  carotids  visibly  throbbing ; 
cough  dry,  violent,  hollow  and  spasmodic,  aggravated  by  cold, 
motion  and  at  night ;  voice  husky  and  very  hoarse ;  larnyx 
painful,  swollen,  and  inflamed ;  sweat  on  covered  parts  ;  cramp- 
like pain  in  upper  part  of  chest. 

Calcarea  carb. — Cough  dry,  short  and  hacking,  worse  even- 
ings  and  when  lying  down  ;  expectoration  of  thick,  yellowish, 
offensive  mucus,  sometimes  tinged  with  blood.  Especially 
useful  in  light-haired,  plump  children  of  a  scrofulous  diathesis; 
calc.  phos.  useful  in  same  cases,  calc.  iod.  in  tubercular  patients. 

Drosera.  —  Violent  paroxysms  of  cough  following  each 
other  so  rapidly  that  patient  loses  his  breath  ;  cough  dry,  hard 
and  spasmodic,  and  followed  by  nausea  and  vomiting ,  aphonia ; 
cough  aggravated  at  night  and  when  lying  down  ;  breathing 
rapid  and  oppressed  ;  alternate  diarrhea  and  constipation. 

Fcrriim  met. — Rough,  hoarse  voice ;  dyspnea ;  small,  weak 
rapid  pulse ;  coughs  up  bloody  mucus  or  pus  in  mornings ; 
cough  dry  and  rasping  at  night ;  epistaxis ;  great  emaciation, 
weakness  and  prostration  ;  voracious  appetite,  with  extension 
of  abdomen  ;  stools  sudden,  watery  and  painless.  Especially 
useful  in  tuberculosis. 

Hepar  sulph. — Cough  deep,  rough,  barking  and  excited  by 
the  least  cold  striking  the  body  ;  rattling  of  tenacious  mucus  in 
chest;  almost  complete  loss  of  voice;  raw,  scraped  feeling  in 
throat,  with  sensation  as  if  splinter  were  sticking  there,  worse 
on  swallowing;  chilliness  in  open  air;  high  fever  with  perspira- 
tion ;  sweats  on  slightest  exertion  ;  stitches  and  pains  in  palms 
of  hands  and  soles  of  feet. 

Ipecac. — Audible,  coarse  rattling  of  mucus  in  chest ;  in- 
tense nausea  and  long-lasting  vomiting ;  dyspnea,  with  short, 
wheezing  respirations;  paroxysms  of  violent,  convulsive  cough- 
ing, so  violent  that  child  turns  blue  in  the  face  and  becomes 
rigid  ;  paroxysms  of  cough  cause  nausea  and  vomiting. 
D.  C— 38 


594  THE  DISEASES  OF  CHILDREN. 

Phosphorus. — Voice  hoarse,  husky  and  rough,  cannot  speak 
above  a  whisper  mornings ;  short,  dry,  convulsive  metallic 
cough  ;  dyspnea,  with  pain  in  chest ;  expectoration  of  bloody, 
frothy,  tenacious,  purulent  mucus ;  rawness  in  larynx,  with  dif- 
ficult expectoration  ;  palpitation  of  heart ;  pulse  small,  full,  hard 
and  rapid,  or  weak  and  compressible  ;  extreme  emaciation  and 
weakness  ;  loss  of  appetite,  with  nausea  and  vomiting  ;  diarrhea, 
stools  watery,  green  and  streaked  with  blood. 

Pulsatilla. — Hard,  dry  cough  at  night,  but  loose  and  moist 
during  the  day,  aggravated  by  warmth,  and  when  lying  down  ; 
difficult  expectoration  of  thick,  yellow,  saltish  mucus ;  thirst- 
lessness ;  cannot  retain  fatty  foods,  vomits  them  as  soon  as 
eaten  ;  diarrhea  of  green,  slimy  mucus,  or  feces  mixed  with 
mucus,  preceded  by  rumbling;  involuntary  micturation  in  little 
girls,  especially  while  coughing.  Especially  useful  in  light- 
complexioned  children. 

Sanguinaria. — Breath  and  expectoration  exceedingly  offen- 
sive ;  throat  sore,  dry  and  feels  as  if  denuded ;  cough  dry  and 
hacking ;  severe  dyspnea  and  difficult  expectoration  ;  pain  in 
right  chest,  extending  to  shoulder ;  circumscribed  redness  of 
one  or  both  cheeks  ;  hands  cold,  with  ulcers  forming  about  the 
nails ;  loose  stools  followed  by  flatus. 

Sulphur. — Weakness,  with  bruised  pain  in  upper  part  of 
chest  ;  stitches  in  chest,  extending  through  the  shoulder  and 
back,  worse  on  moving  and  when  lying  down  ;  aphonia ;  cough 
dry,  short  and  violent,  with  expectoration  of  purulent  mucus ; 
dyspnea;  hemoptysis;  profuse  nocturnal  perspiration  ;  itching 
in  rectum,  with  soft  stools ;  no  appetite ;  scrofulous  subjects 
with  boils,  abscesses  and  enlarged  glands. 


CHAPTER  XII. 

PLEURITIS  (pleurisy). 

Pleurisy  is  an  inflammation  of  the  pleural  membrane, 
attended  in  all  cases  with  an  exudation  into  the  pleural  sac  of 
serum  or  sero-fibrinous  fluid,  which  has  a  strong  tendency  to 
become  purulent.  It  may  be  primary  or  secondary,  acute  or 
chronic,  circumscribed  or  general.  It  is  less  frequent  in  chil- 
dren than  adults,  but  is  by  no  means  rare  even  in  young  infants. 
It  aff^ects  the  two  sexes  in  about  equal  proportions,  although 
some  authorities  have  noticed  a  slight  preponderance  in  boys. 
In  Goodhart's  experience,  empyematous  pleurisy  affected  the 
left  side  more  often  than  the  right,  in  the  proportion  of  four  to 
one.  In  uncomplicated  cases — that  is  to  say,  when  not  asso- 
ciated with  phthisis,  pneumonia,  or  septicemia — it  is  nearly 
always  unilateral.  The  pleurisy  of  childhood  is  more  apt  to  be 
purulent  than  sero-fibrinous. 

Etiology. — Primary  pleurisy  is  most  common  in  the  spring 
and  fall,  when  the  weather  is  changeable,  and  ordinary  colds 
and  catarrhs  are  prevailing.  Children  who  are  enfeebled  by 
previous  illnesses,  or  neglect,  or  whose  constitutions  are  below 
par  by  reason  of  hereditary  influences,  are  most  subject  to  the 
disease.  "  Taking  cold  "  is  probably  the  chief  cause  of  the 
affection  in  its  primary  form. 

Secondary  pleurisy  is  due  to  a  great  variety  of  causes. 
Sometimes  a  trifling  bruise  on  the  chest  will  cause  it.  It  is 
frequent  in  acute  nephritis,  whether  scarlatinal  or  otherwise. 
It  is  a  common  complication  of  tubercular  disease  of  the  lungs, 
bronchitis,  bronchiectasis,  disease  of  the  bronchial  glands, 
pneumonia  of  both  kinds,  pericarditis,  scarlatina  and  acute 
rheumatism.  It  is  frequently  seen  in  connection  with  diseases 
below  the  diaphragm,  such  as  peritonitis,  appendicitis  and 
affections  of  the  liver  and  spleen.  Probably  there  are  many 
cases  of  pleurisy  that  cannot  be  traced  to  any  recognizable 
cause,  and  which  must,  therefore,  be  classed  as  idiopathic. 

The  pathology  of  infantile  pleurisy  does  not  differ  from  that 
of  adults,  except  in  the  greater  tendency  in  children  for  the 
exudation  to  become  purulent.  The  exudation  in  some  cases 
is  nearly  all  fibrinous,  gluing  the  lung  to  the  thoracic  wall,  and 
forming  firm  adhesions,  which  may  last  a  lifetime.     These  are 

(595) 


596  THE  DISEASES  OF  CHILDREN. 

the  cases  which  are  called  "  dry  pleurisy."  In  autopsies  such 
adhesions  are  frequently  found,  which  had  not  attracted  atten- 
tion during  life.  In  other  cases,  the  effused  liquid  consists  of 
serum,  leucocytes,  and  pus  cells.  Occasionally,  though  very 
rarely,  blood  is  effused,  constituting  what  is  known  as  hem- 
orrhagic pleurisy.  The  liquid  is  usually  transparent,  rich  in 
albumin,  and  is  of  a  light  yellow  or  greenish  tint.  When  drawn 
off  with  an  aspirator,  it  coagulates  spontaneously  into  a  soft, 
jelly-like  mass. 

The  amount  of  fluid  which  is  exuded  in  some  cases  of  pleurisy 
is  enormous.  In  the  case  of  a  child  twenty-two  months  old,  a 
pint  and  a  half  of  fluid  was  found  in  the  left  pleural  sac.  Ziemssen 
records  a  case  of  a  girl  three  years  old,  at  whose  autopsy  two 
and  a  half  pounds  of  fluid  were  found  in  the  right  chest.  Hey- 
felder  removed  by  thoracentesis  six  pints  of  pus  from  a  boy  of 
six  years.  Such  enormous  quantities  as  these  are  very  excep- 
tional. Sometimes  the  exploratory  needle  fails  to  find  any  ex- 
udation at  all,  the  effusion  being  of  the  fibrinous  variety,  and 
being  only  sufficient  in  amount  to  agglutinate  the  pleural  sur- 
faces. It  is  not  common  to  find  more  than  a  few  ounces,  except 
in  rare  instances.  J.  Lewis  Smith  says  that  at  the  age  of  four 
months,  three  ounces  of  fluid  are  sufficient  to  produce  complete 
collapse  of  the  lung,  and  it  is  stated  that  this  same  amount  in 
a  child  a  year  old  will  give  rise  to  well-marked  flatness  on  per- 
cussion. Any  considerable  amount  of  fluid  in  the  pleural  cav- 
ity must,  of  necessity,  produce  compression  upon  the  contigu- 
ous lung,  and  when  occurring  in  the  left  chest,  it  may  seriously 
embarrass  the  action  of  the  heart. 

The  heart  itself  may  be  pushed  into  the  left  axilla,  or  crowded 
over  to  the  right  of  the  sternum.  The  natural  tendency  of  the 
effused  liquid  is  to  press  the  ribs  apart  and  to  produce  a  bulg- 
ing of  the  intercostal  spaces ;  but  in  young  infants,  the  lungs 
collapse  so  readily  from  pressure,  that  but  little  distension  may 
be  noticeable,  unless  the  chest  is  half  full  of  fluid.  Where  the 
effused  liquid  is  sero-fibrinous,  much  of  it  is  ultimately  ab- 
sorbed, while  the  remainder  is  organized  into  the  adhesive 
bands  before  alluded  to,  which  bind  down  the  lungs,  sometimes 
to  the  extent  of  producing  deformity  ;  in  other  cases  of  milder 
type  and  trifling  exudation,  no  serious  effects  are  experienced. 
It  is  doubtful  if  purulent  effusions  are  ever  absorbed.  They 
either  cause  the  ultimate  death  of  the  patient,  or  in  more  favor- 
able cases,  the  pus  is  discharged,  either  into  a  bronchus  or  out- 
wardly by  way  of  an  abscess.  Cases  have  been  known  where 
the  emphysema  has  caused  peritonitis,  a  lumbar  abscess,  or  has 
pointed  into  the  esophagus. 

Symptoms. — Pain,  which  is  of   such  a  marked  and  definite 


PLEURITIS  {PLEURISY).  597 

character  in  adults  affected  with  pleurisy,  is  more  variable  and 
of  less  significance  in  infants  and  children.  In  some  instances 
the  pain  is  intense,  so  that  respiration  is  restricted,  causing  the 
child  to  hold  his  breath,  and  to  fix  the  diaphragm,  so  that  the 
breathing  becomes  abdominal  rather  than  thoracic.  In  other 
cases,  and  these  are  more  common,  the  pain  is  distributed  over 
the  subscapular,  subclavicular,  and  soon  over  the  umbilical  and 
hypogastric  regions.  There  is,  however,  great  hyperesthesia 
over  the  affected  areas,  a  sensitiveness  to  touch  which  comes 
from  an  implication  of  the  intercostal  nerves.  This  cutaneous 
sensitiveness  in  many  cases  constitutes  the  bulk  of  the  subjec- 
tive symptoms.  No  acute  pain  of  a  local  kind  is  complained 
of  in  many  cases,  unless  it  is  inquired  for,  and  even  then  it  is 
but  vaguely  indicated. 

The  acuteness  of  the  symptoms  in  the  outset  is  exceedingly 
variable.  In  some  cases,  especially  in  children  past  the  denti- 
tion period,  there  may  be  chilliness,  headache,  fever,  and  oc- 
casionally in  younger  children,  convulsions.  Vomiting  is 
sometimes  met  with ;  in  short,  the  initial  symptoms  are  so 
variable  that  in  the  absence  of  lateral  pain  the  diagnosis  is  apt 
to  be  obscured.  Cough  is  not  an  essential  symptom  in  pleu- 
risy, although  it  is  commonly  present.  In  contrast  with  these 
mild  and  doubtful  cases,  there  are  many  who  experience  sudden 
and  violent  symptoms  of  unmistakable  import,  such  as  violent 
pain  in  the  side,  sharp  in  character  and  cutting  like  a  knife,  or 
incisive  and  piercing  like  a  dagger.  Such  cases  are  apt  to  be 
pneumonic  as  to  their  cause  (pleuro-pneumonia),  and  the  efTu- 
sion  is  apt  to  be  purulent  from  the  beginning. 

The  temperature  in  pleurisy  is  subject  to  great  variations. 
Mild  cases  may  have  none  at  all,  worth  recording.  In  other 
cases  the  thermometer  may  register  as  high  as  103°,  or  even 
higher.  The  average  temperature  in  pleurisy  is  probably  not 
over  ioi°-io5°  Fahr.  In  mild  and  medium  cases  the  tempera- 
ture falls  as  soon  as  effusion  is  complete,  that  is  to  say,  within 
twelve  to  forty-eight  hours.  If  prolonged  beyond  this  period, 
there  is  likely  to  be  pneumonia  present  as  well  as  pleurisy. 

In  purulent  pleurisy — that  is  to  say,  in  nearly  one-half  of  all 
cases — there  is  sudden  and  progressive  emaciation.  This  is  often 
rapid  and  extreme,  and  occurs  in  cases  in  which  the  onset  is 
mild  and  the  symptoms  vague,  as  well  as  those  which  are  of 
more  violent  nature.  In  idiopathic  cases  the  symptoms  are 
usually  more  definite  and  pronounced  than  in  cases  following 
some  other  disease.  Indeed,  as  a  secondary  affection,  pleurisy 
is  commonly  very  insidious,  and  unless  under  the  eye  of  an 
alert  physician,  may  escape  notice  until  purulent  effusion  has 
made  serious  progress. 


598  THE  DISEASES  OF  CHILDREN. 

In  some  cases  there  is  pallor  of  countenance  and  a  puffiness 
of  the  face,  suggestive  of  Bright's  disease.  In  such  cases  an 
examination  of  the  urine  will  serve  to  avoid  mistakes.  In  cases 
where  there  is  great  emaciation  and  much  general  prostration, 
there  may  be  no  elevation  of  temperature,  except  in  cases 
where  the  pus  has  been  evacuated,  either  spontaneously  or  by 
operation.  In  these  latter  cases,  a  reformation  of  pus  is  imme- 
diately followed  by  a  rise  of  temperature.  Diarrhea  and  sweat- 
ing are  also  indicative  of  pus  formation,  either  primarily  or 
after  operation.  As  a  rule,  in  mild  or  moderately  severe  cases, 
the  temperature  runs  a  pretty  regular  course,  being  somewhat 
higher  in  the  evening,  but  not  showing  any  erratic  rises,  unless 
caused  by  pus. 

Goodhart  calls  attention  to  a  negative  sign  which  should  be 
borne  in  mind  in  the  consideration  of  all  doubtful  cases,  viz., 
the  absence  of  any  indications  of  distress  in  breathing.  He 
says:  "Such  a  thing  might,  otherwise,  be  thought  impossible 
with  one  or  other  side  of  the  chest  full  of  fluid.  Yet  not  only 
may  this  be  so,  but  even  the  heart  may  be  considerably  dis- 
placed without  symptoms.  This  is  noticed  in  the  more  chronic 
cases,  and  is  not  difficult  to  explain.  A  like  phenomenon  is 
present  in  many  cases  of  phthisis,  and  it  is  dependent  in  great 
part  upon  the  compensation  which  takes  place  as  the  disease 
progresses,  the  emaciated  body  requiring  diminished  action  of 
the  lung." 

Physical  Signs. — There  are  certain  differences  in  the  physical 
signs  of  pleurisy  occurring  in  children  and  adults.  In  young 
infants  these  differences  are  usually  very  marked.  In  the  com- 
mencement of  an  attack  there  is  a  diminution  in  the  movement 
of  the  chest  walls  on  the  affected  side,  due  to  the  patient's  in- 
stinctive efforts  to  repress  the  respiratory  action  on  that  side, 
in  order  to  lessen  the  pain.  The  respiration,  is,  therefore, 
largely  confined  to  the  unaffected  side,  and  is  hastened  in  con- 
sequence. 

After  effusion  has  taken  place,  the  pain  abates,  and  the  res- 
piration is  less  accelerated  than  at  first ;  indeed,  it  may  be 
nearly  or  quite  normal.  The  bulging  of  the  intercostal  spaces, 
and  the  consequent  inequality  of  the  two  sides,  is  made  much 
of  by  some  authors,  but,  in  fact,  in  infants,  even  where  there 
is  a  large  amount  of  exudation,  the  bulging  is  often  so  trifling 
as  to  be  practically  inappreciable,  either  to  sight  or  measure- 
ment. This  is  probably  due,  in  most  cases,  to  the  collapse  of 
the  thin  borders  of  the  lung  and  semi-collapse  of,  perhaps,  the 
w^hole  lung  on  the  affected  side.  This  is  very  apt  to  occur  in 
weakly  infants,  and  especially  those  who  have  been  reduced  by 
previous  sickness,  even  when  there  is  no  obstruction  to  the 


PLEURITIS  {PLEURISY).  599 

entrance  of  a'r  to  the  lungs.  It  is  brought  about  by  the  pressure 
of  the  effused  liquid,  so  that  the  lung  recedes  from  the  ribs  and 
becomes  lessened  in  actual  size,  more  than  enough  to  compen- 
sate for  the  space  occupied  by  the  fluid.  In  children  with 
strong  vocal  organs,  vocal  fremitus  will  not  be  found  over  the 
seat  of  effusion,  but  will  be  marked  in  the  axillary,  suprascap- 
ular, infraclavicular,  or  mammary  region,  where  the  compressed 
lung  comes  in  contact  with  the  walls  of  the  chest. 

When  there  is  fluid  at  the  base  of  the  chest,  the  apex  reso- 
nance on  the  affected  side  will  be  modified  and  have  a  high- 
pitched,  tympanitic  note,  very  different  from  the  natural,  deep 
resonance  of  health.  It  should  be  borne  in  mind,  however, 
that  percussion  does  not  afford  the  same  degree  of  accuracy  in 
determining  the  amount  of  fluid  as  in  adults,  because  the  vi- 
bratory movements  of  the  chest  are  more  easily  set  up,  and 
the  sonority  of  the  lung  much  more  easily  brought  out,  and 
there  is  a  much  readier  development  of  the  tympanitic  quality  of 
resonance.  Indeed,  it  is  only  in  the  later  stages  that  we  are 
able  to  determine,  by  percussion,  the  outlines  of  a  large  effu- 
sion, and  the  degree  of  displacement  effected  by  it  of  adjacent 
organs.  The  physical  signs  to  be  determined  by  means  of  the 
stethoscope  are  quite  inconstant  in  infancy,  and  in  all  pulmo- 
nary affections  are  so  variable  that  no  two  observations  are  likely 
to  correspond.  The  friction-rales,  which  are  so  noticeable  in 
adult  pleuritis,  may  be  altogether  wanting  in  infants,  until  after 
absorption  has  begun. 

The  real  friction  sound  may  be  heard  in  some  cases  for  a 
brief  period,  and  then  it  may  disappear  for  a  time,  to  recur  at 
some  later  stage  of  the  disease.  It  is  never  present  when  the 
accumulation  of  liquid  is  sufficient  to  prevent  contact  of  the 
surfaces.  In  pleuritic  patients  under  five  years,  the  ausculta- 
tory sounds  are  not  modified,  as  in  older  persons,  by  the  in- 
crease and  decrease  of  the  liquid.  In  such  cases,  it  is  rare  not 
to  be  able  to  recognize  the  respiratory  murmur  when  the  ear 
or  the  stethoscope  is  placed  over  the  effusion.  It  may  have  a 
weak  and  far-away  sound,  but  it  is  still  there.  This  is  due  to 
the  small  size  of  the  chest,  and  the  consequent  ready  transmis- 
sion of  sound  from  the  center  of  the  thorax  to  its  periphery. 

If  the  inflammation  be  chiefly  plastic,  or  the  exudation  of 
liquid  proceeds  slowly,  and  its  quantity  be  small,  the  respira- 
tory murmur  may  be  vesicular,  though  faint  and  distant,  dur- 
ing the  whole  course  of  the  attack.  Sometimes,  when  the 
murmur  is  vesicular  in  the  greater  part  of  the  lung,  broncho- 
vesicular  or  bronchial  respiration  is  heard  over  a  limited  area, 
where  the  effusion  happens  to  be  sufficient  to  produce  requisite 
compression  of  the  lung. 


600  THE  DISEASES  OF  CHILDREN. 

Diagnosis.- — Sometimes  a  mere  inspection  of  a  patient  suffer- 
ing from  pleurisy,  may  be  sufificient  to  at  least  suggest  the 
nature  of  the  trouble.  The  face  in  a  typical  case  is  expressive 
of  pain,  the  brow  is  wrinkled,  and  the  lips  compressed.  The 
rhythm  of  the  respirations  is  broken,  and  they  are  irregular  and 
jerking ;  as  far  as  possible  they  are  repressed  on  the  affected 
side  and  correspondingly  increased  on  the  well  side.  The  rate 
is  increased  to  meet  the  demands  of  restricted  oxygenation^ 
and  remains  abnormally  rapid  throughout  the  course  of  the 
disease.  When  the  pleurisy  is  on  the  left  side,  and  the  effusion 
is  sufficient  to  affect  the  position  of  the  heart,  the  absence  of 
its  apex  beat  from  its  normal  place,  is  a  diagnostic  sign  of  much 
importance.  A  misplaced  heart  apex,  accompanied  with  acute 
symptoms,  should  always  be  looked  upon  with  suspicion  in 
this  connection.  When  the  pleuritic  inflammation  is  circum- 
scribed, and  attended  with  but  little  exudation,  the  diagnosis 
is  often  attended  with  much  difificulty.  The  prominent  symp- 
toms in  the  commencement  are  nearly  identical  with  those  of 
pneumonia.  Still  there  are  essential  differences.  In  pleurisy^ 
both  the  pulse  and  the  respirations  are  more  accelerated  than 
in  pneumonia,  but  the  temperature  is  not  apt  to  be  so  high. 
The  evident  attempt  to  lessen  the  pain  by  a  partial  arrest  of 
the  respiratory  movements,  is  not  seen  in  pneumonia,  nor  is 
there  in  the  latter  disease  that  hypersensitiveness  of  the  cuta- 
neous surfaces  about  the  chest  that  is  so  marked  a  feature  in 
pleurisy.  Another  diagnostic  feature  of  value  in  distinguish- 
ing between  the  two  diseases,  results  from  the  fact  that  the 
pneumonia  of  children  under  five  is  nearly  always  catarrhal 
(broncho-pneumonia),  and  is,  therefore,  preceded  by  more  or 
less  bronchitis.  It  is,  therefore,  gradual  in  its  approach,  and 
not  of  abrupt  development,  like  an  attack  of  pleurisy.  The 
hypersensitiveness  of  the  thoracic  walls,  which  is  present  in 
intercostal  rheumatism  or  neuralgia,  is  liable  to  mislead,  but  in 
pleurisy  the  sharpest  pains  are  on  one  side  and  remain  there, 
while  in  case  the  muscles  are  alone  involved,  the  pains  are  wan- 
dering and  unsteady.  Phthisis  is  not  likely  to  be  mistaken  for 
pleurisy,  even  if  acute,  because  in  this  disease  there  is  usually 
dullness  over  the  apex  of  the  lung,  and  an  absence  of  respira- 
tory murmur;  while  in  pleurisy  we  find  at  the  apex  that  modi- 
fied resonance  before  alluded  to.  This  diminished  or  tympanitic 
resonance  at  the  apex,  due  to  pleuritic  exudation  at  the  base, 
is  in  children  almost  pathognomonic  of  pleurisy.  The  advice 
given  by  some  recent  authorities  to  ascertain  whether  there  be 
exudation  or  not,  and  if  so,  whether  it  is  purulent  or  not,  by 
means  of  an  exploring  needle,  is  only  mentioned  in  order  to 
condemn  it.     Such  a  p.ocedure  is  only  practiced  and  sanctioned 


PL  E  URI TIS—  TREA  TMEN  T.  601 

by  those  who  have  less  regard  for  the  life  of  the  patient  than 
for  so-called  "  scientific  diagnosis."  So  far  as  treatment  goes, 
it  makes  no  special  difference  whether  the  exudation  is  fibrin- 
ous, serous  or  purulent. 

The  effort  of  the  physician  should  be  addressed  to  reducing 
the  inflammation,  and  supporting  the  strength  of  the  patient, 
until  such  time  as  nature  can  bring  about  resolution. 

Prognosis. — Simple,  idiopathic  pleurisy  is  rarely  fatal,  unless 
complicated  with  tubercle  or  pneumonia,  pleurisy,  even  when 
attended  with  a  large  amount  of  serous  or  fibrinous  exudation, 
generally  clears  up  with  great  rapidity  and  without  leaving  be- 
hind any  serious  or  permanent  damage.  In  emphysematous 
pleurisy  the  prognosis  is  more  grave.  A  chest  full  of  pus  is  of 
necessity  a  serious  matter.  But  such  cases  are  of  extreme 
rarity.  When  they  do  occur,  of  course  common  sense  sug- 
gests the  propriety  of  an  outward  evacuation  of  the  purulent 
matter,  by  means  of  puncture  and  a  drainage  tube.  When 
this  operation  is  resorted  to  suflficiently  early,  there  is  every 
reason  to  hope  for  a  favorable  termination,  for  antiseptic 
surgery  is  to-day  attended  in  such  operations  with  but  little 
danger. 

Treatnieyit. — There  are  two  remedies  of  the  greatest  value  in 
the  incipient  stage  of  pleurisy,  which,  given  separately  or  in  al- 
ternation, will  frequently  abort  the  disease,  prevent  effusion,  and 
afTord  prompt  relief  to  the  most  distressful  symptoms.  They 
are  aconite  and  bryonia.  Given  early  enough,  they  are  often- 
times suflficient  alone  to  terminate  the  affection  and  render 
other  drugs  unnecessary.  If,  however,  the  stage  of  effusion  is 
reached,  which  often  happens  before  the  physician  sees  the  pa- 
tient, other  measures  and  remedies  may  be  called  for.  These 
remedies  will  be  mentioned  later.  As  we  have  seen,  the  patient 
instinctively  tries  to  lessen  his  pain  by  suppressing  the  move- 
ments of  the  respiratory  muscles  on  the  affected  side.  But  this 
requires  a  tiresome  effort,  and  unaided  is  only  partially  success- 
ful. Much  comfort  will  be  experienced  by  placing  a  bandage 
of  drilling  around  the  chest,  and  making  it  fairly  snug,  but  not 
so  tight  as  to  hamper  the  breathing  of  the  well  side.  Perhaps 
a  better  plan  than  this  is  to  apply  adhesive  straps  over  the  af- 
fected side,  carrying  them  around  from  the  spine  to  the  sternum, 
and  extending  them  from  the  axilla  to  the  base  of  the  thorax. 
If  the  effusion  is  considerable,  and  especially  if  there  is  reason 
to  believe  that  it  is  purulent  in  character,  no  time  should  be 
lost  in  performing  the  operation  of  thoracentesis.  When  per- 
formed with  due  regard  to  antisepsis,  the  operation  is  practi- 
cally unattended  with  danger.  In  any  event,  the  danger  is 
trifling  when  compared  to  that  of  empyema.     The  symptoms 


602  THE  DISEASES  OF  CHILDREN. 

that  render  this  operation  necessary  are  signs  of  depressed 
vitality,  anxious  and  hurried  breathing,  weakened  pulse  and  livid 
or  cyanotic  countenance. 

As  heretofore  stated,  bulging  of  the  intercostal  spaces 
affords  no  criterion  by  which  to  judge  of  the  amount  of 
fluid  in  the  chest,  and  there  is  no  positive  means  of  determin- 
ing the  character  of  the  fluid,  except  by  using  the  trocar 
or  exploring  needle.  In  some  instances  the  operation  may 
need  to  be  repeated,  in  which  case  a  free  incision  should 
be  made  through  an  intercostal  space,  and  a  suitable  drain- 
age tube  left  to  keep  the  cavity  free  from  further  accumu- 
lation. 

The  method  of  performing  this  operation  and  the  precautions 
necessary  to  be  observed,  more  properly  belong  to  works  on 
surgery,  to  which  the  reader  is  referred. 

Remedies. — Aconite  in  first  stage  ;  fever  ;  pain,  sharp  or  Ian- 
cinating  in  character ;  anxiety ;  restlessness ;  dry  cough ; 
chills  or  chilliness ;  indeed,  all  of  the  symptoms  of  acute 
pleurisy. 

Bryonia. — May  be  alternated  with  aconite  or  given  alone,  if 
the  first  remedy  does  not  quickly  show  amelioration  of  symp- 
toms. It  is  a  most  useful  remedy  all  through  the  attack,  and 
especially  in  secondary  pleurisy  of  the  plastic  variety,  which  is 
circumscribed  in  extent.  The  severe,  sharp  pains  are  aggra- 
vated by  every  motion.  There  is  great  thirst,  tongue  coated 
white,  and  there  is  experienced  much  relief  by  patient  lying  on 
the  affected  side. 

Cantharides. — Jousset  extols  this  remedy  most  highly.  He 
uses  it  in  the  third  dilution  usually,  but  if  this  does  not  show 
prompt  alleviation  he  descends  to  the  second  or  first  dilution, 
or  even  the  mother  tincture.  Its  special  symptoms  are  :  a  pro- 
fuse serous  exudation,  great  dyspnea,  cough  and  palpitation  of 
the  heart,  a  tendency  to  syncope  with  heavy  sweats  and  scanty 
urine. 

Arsenicum. — Great  prostration  and  tendency  to  collapse. 
The  effusion  is  rapid  and  copious.  In  empyema  this  is  the 
prince  of  remedies. 

Apis  mel. — Great  dyspnea ;  the  patient  is  unable  to  lie 
down,  and  feels  as  if  he  could  not  draw  another  breath.  The 
urine  is  scanty.  The  action  of  this  drug  is  in  the  main  very 
similar  to  cantharis.  Both  are  useful  after  effusion  has  taken 
place. 

Hepar  sulph. — In  chronic  cases,  and  when  the  exudation  has 
become  purulent ;  there  are  intermittent  paroxysms  of  hectic 
fever  ;  the  face  has  a  dirty,  yellowish  tint ;  very  useful  in  scrof- 


PLE  URITIS—  THE  A  TMENT.  603 

ulous  and  lymphatic  subjects.     This  remedy,  with  arsenicum 
and  silicia,  will  work  wonders  in  many  cases. 

Merc.  iod. — This  remedy  is  indicated  in  cases  where  the 
absorption  is  slow  or  negative  ;  useful  in  cases  where  the  effusion 
is  serous  or  sero-plastic.  It  is  also  useful  when  the  exudation, 
tends  from  the  first  to  become  purulent ;  chilly  sensations ; 
burning  heat  and  copious  sweats.  See  also  asclepias,  kali  iod., 
hellebore,  lycop.,  and  rhus  tox. 


PART     X. 

GENERAL     DISEASES. 


CHAPTER    I. 

CEREBRO-SPINAL   FEVER  (EPIDEMIC  MENINGITIS;   MALIGNANT 
MENINGITIS;   SPOTTED   FEVER). 

Definition. — Cerebro-spinal  fever  is  a  specific,  non-contagious 
inflammation  of  the  meninges  of  the  brain  and  spinal  cord^ 
having  an  abrupt  beginning  and  an  indefinite  termination.  In 
non-fatal  cases  it  is  apt  to  be  followed  by  serious  and  lasting 
sequelae,  such  as  paralysis,  total  or  partial,  loss  of  sight  or  hear- 
ing, or  protracted  disease  of  the  kidneys.  It  has  no  premoni- 
tory stage,  but  attacks  its  victims  in  the  midst  of  perfect  health, 
and  is  sometimes  fatal  in  a  few  hours.  More  often  it  pursues 
an  erratic  course,  with  frequent  exacerbations,  and  terminates 
in  recovery  or  death  after  weeks  or  months  of  suffering.  It  is 
not  confined  absolutely  to  early  life,  although  a  large  propor- 
tion of  cases  occur  under  five  years  of  age.  Dr.  Sanderson's 
statistics,  covering  an  epidemic  in  which  there  were  two  hun- 
dred and  thirty-five  deaths,  showed  that  all  but  seventeen  were 
under  fourteen  years  of  age.  Like  the  eruptive  fevers,  it  is 
strongly  inclined  to  be  epidemic,  and  in  most  of  the  large  cities 
it  is  now  endemic. 

History. — Notwithstanding  the  fact  that  this  disease  has  been 
found  in  certain  localities  in  nearly  every  civilized  country,  and 
is  everywhere  attended  with  frightful  mortality,  it  is  scarcely 
mentioned  by  a  single  European  writer  on  diseases  of  children, 
and  only  one  American  author  seems  to  have  given  it  more 
than  casual  attention.  This  is  doubtless  due  to  the  fact  that 
the  disease  has  been  generally  confounded  with  either  simple 
or  cerebro-spinal  meningitis,  which  is  altogether  a  different 
affection. 

The  only  clear  and  full  account  of  cerebro-spinal  fever  which 
we  have  been  able  to  find  is  from  the  pen  of  J.  Lewis  Smith,  in 
the  sixth  edition  of  his  valuable  work  on  the  "  Diseases  of  In- 
fancy and  Childhood,"  from  which  much  of  the  following 
(604) 


CEREBROSPINAL  FEVER.  605 

description  has  been  taken.  He  says  if  there  were  cases  of  the 
disease  prior  to  the  present  century  they  must  have  been  un- 
recognized. 

The  history  of  the  disease  in  this  country  previous  to  i860 
is  very  uncertain  and  indefinite.  Since  that  date  it  seems  to 
have  become  established  or  "  naturalized  "  in  many  cities  of  the 
United  States,  and  for  some  years  not  a  week  has  passed  with- 
out the  report  of  deaths  from  this  cause  in  New  York,  Phila- 
delphia, Jersey  City  and  Chicago.  It  is  probably  also  permanently 
established  in  all  of  the  large  cities  as  far  west  as  San  Francisco. 

In  New  York  City  a  severe  epidemic  began  in  December, 
1 87 1,  and  continued  during  the  first  half  of  1872.  Many  of  the 
cases  which  recovered  from  the  attack  did  so  with  permanent 
loss  of  sight  or  hearing.  During  1872  there  were  seven  hun- 
dred and  eighty-two  deaths  from  the  disease  within  the  city 
limits,  most  of  which  were  of  children.  In  this  epidemic  many 
of  the  lower  animals  were  attacked,  especially  the  jaded  horses 
of  the  city  car  and  omnibus  lines.  Since  this  time  the  disease 
has  been  firmly  established  in  that  city,  and  the  annual  mortal- 
ity has  ranged  from  ninety-seven,  in  1878,  to  four  hundred  and 
sixty-one  in  1881.  Prof.  Stills  states  that  between  1863  and 
1882  it  has  caused  two  thousand  and  forty-nine  deaths  in  the 
city  of  Philadelphia.  It  is  uncertain  when  the  disease  made 
its  first  appearance  in  Chicago,  but  that  it  is  firmly  established 
here  now  is  evidenced  by  the  fact  that  in  1885  one  hundred 
and  forty-two  deaths  were  recorded  from  this  cause,  and  it  oc- 
cupies a  more  or  less  prominent  place  in  the  annual  mortality 
list  since  then.  The  smallest  number  of  deaths  in  any  one 
year  since  1885  was  in  1887,  when  there  were  eighty-one  fatali- 
ties, and  the  largest  was  in  1891,  when  the  number  was  three 
hundred  and  one.  It  has  been  observed  in  Cincinnati,  St. 
Louis,  Milwaukee,  Denver,  Detroit,  New  Orleans  and  Mobile, 
and  it  has  doubtless  obtained  a  footing  in  every  considerable 
city  in  the  land. 

Etiology. — The  direct  or  immediate  cause  of  cerebro-spinal 
fever  is  unknown.  By  some  optimistic  members  of  the  pro- 
fession, this  ignorance  concerning  its  etiology  is  attributed  to 
the  scattered  localities  in  which  the  disease  has  been  observed, 
and  to  the  limited  number  of  cases  thus  far  under  observation. 
As  we  are  still  profoundly  in  the  dark  regarding  the  causation  of 
measles,  scarlatina  and  diphtheria,  after  centuries  of  investiga- 
tions, based  upon  millions  of  typical  cases,  it  is  probable  that 
some  time  will  elapse  before  the  exact  nature  of  cerebro-spinal 
fever  will  be  positively  known. 

We  do  know  some  things,  however,  about  the  predisposing 
causes.      Thus,   while   one  hundred   and   sixty-six   epidemics 


606  THE  DISEASES  OF  CHILDREN. 

occurred  in  Europe  and  the  United  States  in  the  six  months 
commencing  with  December,  only  fifty  were  in  the  remaining 
six  months  of  the  year.  Prof.  Hirsch  collected  statistics  of  a 
large  number  of  epidemics  occurring  mostly  in  Central  Europe, 
and  found  that  fifty-seven  were  in  winter,  or  winter  and  spring, 
eleven  in  spring,  five  between  spring  and  autumn,  four  com- 
menced in  the  autumn  and  extended  into  winter  or  the  ensuing 
spring,  while  six  lasted  the  entire  year.  This  authority  ex- 
presses the  opinion  that  the  excess  of  epidemics  in  the  winter 
months  is  due  mainly  to  the  greater  crowding  and  less  ventila- 
tion in  the  domiciles  during  the  cold  than  during  the  warm 
months,  especially  among  the  European  peasantry.  Dr.  Smith 
says  that  in  New  York  City,  where  the  state  of  the  domiciles  is 
about  the  same  the  year  round,  the  season  appears  to  exert 
little  influence  on  the  prevalence  of  the  disease.  All  author- 
ities agree  that  anti-hygienic  conditions  increase  the  liability 
to  cerebro-spinal  fever.  It  has  prevailed  extensively  in  bar- 
racks where  soldiers  were  closely  crowded  together,  and  is  very 
fatal  among  the  poor  in  the  New  York  tenement  houses.  Dr. 
Smith  narrates  many  striking  examples,  which  show  that  foul 
air  and  overcrowding  increase  not  only  the  number,  but  the 
malignancy  of  cases. 

Some  facts  observed  in  certain  epidemics  would  tend  to  show 
that  the  disease  is  mildly  contagious.  Hirsch  is  quoted  as 
authority  for  the  following  example  of  its  occasional  con- 
tagiousness. A  young  man  sickened  with  cerebro-spinal  fever 
on  February  8.  The  woman  who  nursed  him  returned  to  her 
home  in  a  neighboring  village,  and  there  died  of  the  same  dis- 
ease on  February  26.  To  her  funeral  mourners  came  from  a 
neighboring  township,  and  after  their  return  home,  three  of 
them  died  with  the  same  disease,  one  within  twenty-four  hours, 
another  on  March  4,  and  a  third  on  the  7th.  Smith  relates 
a  case  of  a  boy  who  died  of  the  disease  on  a  Saturday  or  Sun- 
day, and  whose  mother  was  taken  ill  two  days  after  washing 
his  bed  linen,  as  well  as  her  young  infant,  both  perishing  from 
the  same  disease.  It  has  been  observed,  however,  that  where 
multiple  cases  occur  in  a  family,  the  disease  begins  at  such 
irregular  intervals  in  the  different  patients  that  there  can  be 
little  doubt  in  most  instances  that  it  is  not  communicated  from 
one  to  the  other,  but,  like  the  fevers  from  marsh  miasm,  is  pro- 
duced by  exposure  to  the  same  morbific  cause,  existing  outside 
the  individuals,  but  within  or  around  the  premises. 

Numerous  instances  are  cited  in  proof  of  this  position.  The 
strongest  evidence  of  its  non-contagiousness  is  afforded  by  the 
fact  that  a  large  majority  of  the  cases  occur  singly  in  families, 
although  no  attempt  is  made  to  isolate  the  patients.     In  the 


CEREBROSPINAL  FEVER.  607 

few  cases  which  we  have  ourselves  observed,  there  has  been  no 
extension  of  the  disease  to  other  members  of  the  family, 
although  there  were  other  children  of  various  ages  having  unre- 
stricted intercourse  with  the  sick  room.  It  is  highly  probable, 
therefore,  judging  from  all  the  evidence  pro  and  con,  that  the 
disease  is  only  mildly  contagious,  if  it  be  contagious  at  all,  and 
if  numerous  cases  in  a  family  are  affected,  it  is  from  the  same 
original  cause,  acting  upon  all  alike,  rather  than  from  direct 
contagion.  The  question  has  been  discussed  as  to  the  possi- 
bility of  the  disease  being  communicated  from  animals  to  man- 
kind. No  instances  of  the  kind  have  been  observed.  During 
the  epidemic  which  prevailed  in  New  York  in  1872,  those  who 
had  charge  of  the  infected  horses,  as  the  veterinary  surgeons 
and  stable  men,  did  not  contract  the  malady,  at  least  no  more 
frequently  than  others  who  were  not  so  exposed. 

In  some  instances,  an  exciting  cause  of  the  disease  seemed 
to  be  some  depressing  emotion  or  unusual  excitement.  It  is 
probable  that  an  individual  exposed  to  the  epidemic  influence 
may  have  the  disease  precipitated  by  anything  which  suddenly 
lowers  the  vitality,  whether  it  be  protracted  loss  of  sleep,  absti- 
nence from  food,  mental  taxation,  fright,  or  unusual  excitement 
of  any  kind.  Such  exciting  causes  as  those  just  mentioned 
cannot  obtain  in  all  cases,  for  numerous  instances  have  occurred 
in  infants  of  three  and  four  months  of  age,  who  are  not  pre- 
sumed to  be  subject  to  disturbances  of  this  sort.  When  occur- 
ring as  a  primary  disease,  and  its  occurrence  thus  is  the 
distinguishing  feature  between  it  and  acute  meningitis,  it  prob- 
ably affects  susceptible  infants  and  children  who,  in  addition  to 
susceptibility,  are  exposed  to  some  malign  influence,  which 
affects  the  meninges  by  some  power  of  election  inherent  in  the 
poison  itself  or  determined  by  some  accidental  circumstance, 
which  either  shocks  or  exhausts  the  nervous  energies.  While 
there  are  ample  facts  to  justify  the  observations  which 
have  been  made  as  to  the  epidemic  tendency  of  the  disease,  it 
very  often  occurs  sporadically.  In  this  city  (Chicago),  while 
cerebro-spinal  fever  has  been  endemic  for  many  years,  there 
has  at  no  time  been  what  could  be  called  an  epidemic  in  any 
particular  ward  or  section.  The  disease  has  affected  widely 
separated  individuals  in  different  portions  of  the  city,  differing 
greatly  in  this  respect  from  scarlet  fever,  measles  and  typhoid. 

Symptoms. — A  typical  case  of  cerebro-spinal  fever,  which 
recently  occurred  in  our  private  practice,  may  here  be  cited  as 
an  example  of  its  clinical  history  : 

Herbert  G.,  eight  years  of  age,  a  bright,  healthy  and  well- 
developed  lad,  came  home  from  school  on  the  19th  of  January 
last,  at  four  o'clock  in  the  afternoon,  complaining  of  severe 


608  THE  DISEASES  OF  CHILDREN. 

headache.  He  usually  came  home  at  half-past  three,  but  this 
day  he  had  been  somewhat  unruly,  and  the  teacher  had  kept 
him  for  a  half-hour  by  way  of  punishment.  The  misdemeanor 
was  a  slight  one,  but  he  had  persisted  in  doing  what  he  was 
told  not  to  do.  He  made  no  complaint  to  the  teacher  of  feeling 
ill.  He  had  gone  to  school  in  the  morning  as  vivacious  and  well  as 
ever.  He  said  nothing  of  feeling  ill  when  he  came  home  at  noon 
for  lunch.  But  when  he  came  home  at  four  o'clock,  he  com- 
plained bitterly  of  his  head  and  his  right  ear.  He  laid  down 
on  the  loui.ge,  and  at  six  o'clock,  his  supper  hour,  he  tried  to 
drink  some  milk,  but  immediately  threw  it  up.  An  hour  after 
he  had  a  spasm,  or  rather  a  succession  of  spasms. 

I  saw  him  a  little  before  eight  o'clock  that  same  evening. 
The  convulsions  had  then  ceased.  But  he  was  unconscious 
and  rigid.  His  head  was  drawn  back,  but  there  was  no  opis- 
thotonos. His  arms  were  stretched  ouj  and  rigid,  as  were  also 
his  legs.  Both  pupils  were  dilated,  the  left  one  much  more 
than  the  right,  and  both  were  insensible  to  light  and  touch. 
The  face  was  somewhat  bloated  and  intensely  red.  His  bron- 
chi were  filled  with  frothy  mucus,  and  his  respirations  were 
quick  and  accompanied  with  coarse,  rattling  rales.  His  pulse 
was  rapid  and  full.  As  he  could  not  be  induced  to  swallow,  he 
was  given  a  hypodermic  injection  of  ergotin,  cold  applications 
were  applied  to  his  head,  and  mustard  leaves  to  the  soles  of  his 
feet.  These  measures  were  continued  at  intervals  for  a  couple 
of  hours,  when  he  died,  without  a  recurrence  of  spasms  or  a 
return  of  consciousness.  The  duration  of  the  attack  lasted  just 
six  hours.  Inquiry  made  at  the  school  next  day  failed  to 
elicit  a  single  fact  that  shed  any  light  on  the  case.  He  had  his 
lessons  and  behaved  just  as  usual,  except  for  persistently  stick- 
ing one  foot  out  into  the  aisle,  after  being  reprimanded  by  his 
teacher  for  so  doing.  He  had  received  no  injury  from  a  fall  or 
otherwise,  and  up  to  the  time  of  his  leaving  school  in  the  even- 
ing he  seemed  to  have  been  in  perfect  health.  He  was  an  apt 
student  and  ambitious  to  learn.  His  teacher  said  that  he  was 
usually  very  obedient  and  tractable,  but  for  a  Week  or  two  prior 
to  his  sickness  and  death,  she  had  noticed  that  he  had  spells  of 
being  somewhat  sullen  and  a  trifle  willful.  At  home  he  was  fond 
of  showing  off  his  acquirements,  and  was  always  lively  and 
happy.  He  had  never  had  previously  any  sickness  of  any 
magnitude.  There  were  three  other  children  in  the  house  at 
the  time  of  his  death,  all  with  unrestrained  liberty,  but  none 
of  them  contracted  the  disease. 

This  case  is  typical,  in  that  it  exhibited  all  of  the  peculiar 
features  that  distinguish  this  from  the  ordinary  form  of  men- 
ingitis.    Dr.  Smith,  from  whom  we  have  gathered  much  infor- 


CEREBROSPINAL  FEVER.  609 

mation  as  to  the  history  of  the  disease,  and  its  symptoms  in 
New  York,  says :  "  Cerebro-spinal  fever  rarely  begins  in  the 
forenoon,  after  a  night  of  quiet  and  sound  sleep.  .  .  .  The 
commencement  is  usually  without  premonitory  stage,  and  sud- 
den— unlike,  therefore,  the  beginning  of  other  forms  of  menin- 
gitis, which  come  on  gradually,  and  are  preceded  by  symptoms 
which,  if  rightly  interpreted,  direct  attention  to  the  cerebro- 
spinal system.  .  .  .  The  ordinary  mode  of  commencement 
is  as  follows:  the  patient  is  seized  with  vomiting,  headache, 
and  perhaps  a  chill  or  chilliness,  so  that  there  is  a  sudden 
change  from  perfect  health  to  a  state  of  serious  sickness.  .  .  . 
Children  often  have  clonic  convulsions,  in  place  of  the  chill,  or 
immediately  after  it,  partial  or  general,  slight  or  severe.  Stupor 
more  or  less  profound,  or  less  frequently  delirium,  succeeds. 
In  the  gravest  cases,  semi-coma  occurs  within  the  first  few 
hours,  in  which  patients  are  with  difficulty  aroused,  or  profound 
coma,  which,  in  spite  of  prompt  and  appropriate  treatment,  is 
speedily  fatal.  Those  thus  stricken  down  by  the  violent  onset 
of  the  disease,  if  aroused  to  consciousness,  complain  of  severe 
headache,  with  or  without,  or  alternating  with,  equally  severe 
neuralgic  pains  in  some  part  of  the  trunk,  or  in  one  of  the 
extremities.  The  pain  frequently  shifts  from  one  p^rt  to 
another.  Among  the  early  symptoms  of  cerebro-spinal  fever 
are  those  which  pertain  to  the  eye.  The  pupils  are  dilated  or 
less  frequently  contracted,  and  they  respond  feebly  or  not  at 
all,  to  light,  if  the  attack  be  severe  and  dangerous ;  often  they 
oscillate,  and  occasionally  one  is  larger  than  the  other.  Vomit- 
ing with  little  apparent  nausea,  and  often  projectile,  is  common 
in  the  commencement  of  cerebro-spinal  fever.  It  occurred  as 
an  early  symptom  in  fifty-one  of  fifty-six  cases  observed  by 
Dr.  Sanderson.  In  ninety-seven  cases  occurring  in  New  York, 
most  of  them  observed  by  myself,  but  a  few  of  them  related  to 
me  by  the  late  Dr.  John  G.  Sewall,  vomiting  occurred  as  an 
early  symptom  in  sixty-eight  cases.  Its  absence  on  the  first 
day  was  recorded  in  only  three  cases,  while  in  the  remaining 
twenty-seven  cases  the  records  of  the  first  day  make  no  men- 
tion of  its  presence  or  absence.  It  was  probably  present  in 
most  of  these  twenty-seven  cases  as  one  of  the  first  symptoms." 

Clonic  convulsions  are  very  common  in  the  commencement 
of  cerebro-spinal  fever,  but  tonic  muscular  contraction  and  rigid- 
ity are  still  more  so.  This  rigidity  of  the  extremities  is  so  con- 
stant a  symptom  in  the  disease,  occurring  even  in  cases  which 
have  been  without  spasms,  that  it  has  great  diagnostic  value. 
It  sometimes  lasts  for  days,  or  even  weeks,  before  relaxation 
takes  place. 

The  mental  state  of  those  patients  who  are  not  rendered 
D.C.— 39 


610  THE  DISEASES  OF  CHILDREN. 

unconscious  by  the  violence  of  the  attack,  is  one  of  apathy  or 
indifference. 

The  intense  headache,  which  is  referred  to  the  top  of  the 
head  in  some  cases,  and  to  the  occiput  or  frontal  region  in 
others,  is  present  in  all  cases.  It  is  not  only  a  prominent  initial 
symptom,  but  it  continues  through  the  acute  period  of  the 
malady.  It  shifts  about  from  place  to  place,  now  on  top  and 
again  in  the  back  of  the  head  and  nucha.  Pains  are  complained 
of  in  the  epigastrium,  in  the  umbilical  and  lumbar  regions, 
along  the  spine,  and  in  the  extremities.  In  the  head  and  along 
the  spine  it  is  most  severe  and  persistent.  In  prolonged  cases, 
the  pain  abates  after  the  first  few  days,  and  by  the  close  of  the 
second  week  is  much  less  pronounced  than  previously.  Vertigo 
generally  accompanies  the  headache,  so  that  the  patient  reels 
in  attempting  to  stand  or  walk.  In  protracted  cases  there  is 
partial  or  complete  loss  of  appetite,  depending  on  the  severity 
of  the  attack  and  its  attendant  pain,  and  more  or  less  emacia- 
tion ensues  in  consequence.  Vomiting,  which,  as  has  been 
stated,  is  of  common  occurrence,  may  be  an  early  symptom, 
and  last  but  a  few  hours;  or  return  at  irregular  intervals  during 
the  progress  of  the  disease.  It  is  like  all  vomiting  in  cerebral 
cases^  without  nausea  and  attended  with  little  efTort. 

The  tongue  is  usually  moist  and  but  slightly  furred.  The 
sordes  and  brownish  fur,  which  are  so  common  in  typhus  and 
typhoid  fever,  are  seldom  or  never  seen  in  cerebro-spinal  fever. 

In  severe  cases  inability  to  swallow  is  an  early  and  a  promi- 
nent symptom.  The  pulse  is  generally  more  or  less  accelerated, 
and  the  heart's  action  is  more  rapid  in  proportion  to  the  sever- 
ity of  the  attack.  In  exceptional  cases,  where  there  is  com- 
pression of  the  brain,  from  an  abundant  exudation,  there  may 
be  a  pulse  subnormal  in  rapidity.  The  temperature  in  this 
disease  is  subject  to  great  and  rapid  fluctuations.  In  mild  at- 
tacks it  may  not  average  above  the  normal,  especially  during 
the  first  few  days,  while  in  severe  cases  a  higher  temperature 
has  been  recorded  than  in  any  other  disease.  Fluctuations  in 
the  temperature  occur  not  only  from  day  to  day,  but  at  differ- 
ent hours  of  the  same  day.  Smith  mentions  one  case  in  which 
the  thermometer  registered  107  2-5°  Fahr.  This  was  in  the 
commencement  of  an  attack,  the  patient  being  two  years  old. 
Great  and  sudden  variations  of  both  pulse  and  temperature  are 
characteristic  of  the  disease,  and  have,  therefore,  considerable 
diagnostic  value  in  obscure  and  doubtful  cases.  The  skin  is 
often  the  seat  of  papilliform  elevations,  the  so-called  goose 
flesh  of  the  laity,  and  in  cases  where  the  temperature  is  reduced, 
there  is  a  dusky  mottling  of  the  cutaneous  surface  in  severe  or 
grave  cases,  which  has  given  rise  to  the  name  "spotted  fever," 


CEREBROSPINAL  FEVER.  611 

by  which  it  is  sometimes  known.  In  some  epidemics  there  has 
been  noticed  a  tendency  to  extravasations  of  blood  under  the 
cuticle,  resembling  bruises  in  appearance ;  but  this  is  seen  only 
occasionally,  and  apparently  never  in  Europe. 

The  anatomical  and  pathological  changes  which  occur  in  the 
course,  and  as  a  result  of  the  disease,  do  not  differ  materially 
from  those  seen  in  other  forms  of  meningitis,  except  that  they 
are  more  general  and  less  localized.  In  cases  of  great  severity, 
the  inflammatory  exudation,  fibrinous  or  purulent,  or  both, 
covers  nearly,  or  quite,  the  entire  surface  of  the  brain.  As  to 
the  nature  of  the  malady  and  its  differential  diagnosis  from 
kindred  affections.  Smith  thus  sums  up  his  views:  "The  theory 
that  cerebro-spinal  fever  is  a  form  of  typhus,  once  had  its  advo- 
cates, but  it  is  now  so  generally  discarded  as  untenable  and 
absurd,  that  it  would  be  a  waste  of  time  to  consider  the  facts 
which  differentiate  the  two  maladies.  Cerebro-spinal  fever 
should,  therefore,  be  considered  as  distinct  from  all  other 
diseases,  a  malady  sui  generis^  and  in  nosological  writings  it 
should  be  classified  with  those  constitutional  maladies  which 
have  specific  causes." 

Duration. — The  duration  of  cerebro-spinal  fever  is  very  vari- 
able. In  some  epidemics,  and  even  in  sporadic  cases,  the 
attacks  are  so  intense  that  the  system  does  not  withstand  the 
shock  but  a  few  hours.  In  other  cases,  seemingly  mild  at  the 
commencement,  the  disease  is  subject  to  many  exacerbations, 
and  runs  a  very  protracted  course.  Cases  are  recorded  which 
lasted  for  one,  two  and  three  months.  The  after-effects  in 
those  which  recover  are  often  interminable.  Smith  records  a 
case  of  a  child  three  years  of  age  who  lost  her  speech  on  the 
second  day  of  cerebro-spinal  fever,  and  who  was  unable  to 
articulate  even  the  simplest  word  for  two  and  a  half  months. 
Finally,  she  began  to  utter  slowly  and  with  difficulty,  the  easiest 
monosyllables,  and  after  the  lapse  of  more  than  a  year,  her 
speech  was  slow  and  lisping,  her  hands  were  tremulous  and 
unsteady,  she  was  easily  fatigued,  and  cried  often  from  over- 
sensitiveness.  There  are  mild  cases,  however,  of  so  indefinite 
a  type  as  scarcely  to  be  recognized,  and  many  others  whose 
duration  is  favorably  terminated,  either  naturally  or  by  treat- 
ment, in  a  few  days  or  even  hours.  As  has  been  truly  said, 
"There  is  probably  no  disease  which  falsifies  the  predictions  of 
the  physician  more  frequently  than  cerebro-spinal  fever." 
Grave  initial  symptoms  are  sometimes  quickly  dissipated,  and 
do  not  relieve,  while  a  mild  onset  not  infrequently  takes  on  a 
graver  aspect,  and  terminates  fatally  after  a  protracted  siege, 
or  a  slow  and  tedious  convalescence  follows,  after  prolonged 
suffering. 


612  THE  DISEASES  OF  CHILDREN. 

Diagnosis. — The  diagnosis  of  cerebro-spinal  fever  from  the 
other  and  more  common  forms  of  meningitis,  is  usually  not  dif- 
ficult. In  the  former,  the  onset  is  sudden,  and  the  maximum 
intensity  of  symptoms  is  reached  at  a  bound,  or  at  least  in  the 
first  few  days ;  while  in  the  latter,  there  is  a  gradual  and  pro- 
gressive increase  of  symptoms  from  a  comparatively  mild  com- 
mencement. Moreover,  ordinary  meningitis  is  generally  a 
secondary  affection,  being  due  to  tubercle,  bronchitis,  pneumo- 
nia, or  other  disease,  and  is,  therefore,  preceded  and  accom- 
panied by  symptoms  which  are  directly  referable  to  the  primary 
disease.  Cerebro-spinal  fever,  on  the  other  hand,  begins 
abruptly  in  a  state  of  previous  good  health.  Again,  in  cerebro- 
spinal fever,  after  the  second  or  third  day,  there  is  marked 
hyperesthesia,  retraction  of  the  head,  and  other  characteristic 
symptoms,  which  are  either  not  present  or  are  less  pronounced 
in  ordinary  meningitis.  In  the  suddenness  of  its  onset,  and 
the  nature  and  violence  of  its  initial  symptoms,  cerebro-spinal 
fever  is  apt  to  be  mistaken  for  scarlatina.  But  in  the  latter 
afTection  there  is  always  more  or  less  angina,  and  a  few  hours 
later  the  characteristic  efflorescence  appears  on  the  skin.  The 
peculiar  fluctuations  of  pulse  and  temperature  in  cerebro-spinal 
fever  will  also  aid  in  establishing  the  diagnosis.  Scarlatina 
rarely,  if  ever,  has  the  intense,  almost  unbearable,  and  shifting 
cephalalgia  which  is  common  to  the  other  disease. 

Prognosis. — Cerebro-spinal  fever  is  justly  regarded  as  one  of  the 
most  dangerous  maladies  of  childhood.  It  is  to  be  dreaded,  not 
only  on  account  of  the  great  mortality  which  attends  it,  but 
also  on  account  of  its  protracted  course,  the  suffering  which  it 
causes,  the  possible  permanent  injury  of  the  important  organ 
which  is  principally  involved,  and  the  not  infrequent  irreparable 
damage  which  the  eye  and  ear  sustain.  Under  five  years  of  age, 
the  prognosis  is  more  grave  than  when  the  disease  attacks  older 
children.  At  any  age,  an  abrupt  and  violent  commencement,  pro- 
found stupor,  convulsions,  active  delirium  and  great  elevation  of 
temperature,  are  symptoms  which  should  excite  solicitude  and 
render  the  prognosis  guarded.  If  the  temperature  remains  above 
105°  Fahr.  for  a  considerable  time,  death  is  probable,  even  with 
moderate  stupor.  Numerous  and  large  petechial  eruptions  show 
a  profoundly  altered  state  of  the  blood,  and  are,  therefore,  a 
bad  prognostic,  and  so  is  albuminuria,  since  it  shows  great  blood 
change,  or  nephritis,  while  other  organs  than  the  kidneys  are 
probably  also  involved. 

A  mild  commencement,  with  general  mildness  of  symptoms, 
as  the  ability  to  comprehend  and  answer  questions,  moderate 
pain  and  muscular  rigidity,  some  appetite,  moderate  emaciation, 
little  vomiting,  etc.,  justify  a  favorable  prognosis  ;  but  even  in 


CEREBROSPINAL  FEVER.  613 

such  cases  it  should  be  guarded  till  convalescence  is  fully 
established. 

Treatment. — The  treatment  of  cerebro-spinal  fever  must  be 
palliative  as  well  as  medicinal.  There  is  intense  hyperemia  of 
the  brain  and  spinal  cord,  and  our  efforts  must  be  directed  to 
relieve  this  as  speedily  as  possible,  and  subdue  or  diminish  the 
inflammation.  A  hot  mustard  foot  bath,  or  a  general  hot  bath, 
in  cases  in  which  convulsions  are  present  or  threatening,  is  a 
useful  measure,  as  it  is  calmative  and  acts  as  a  derivative  from 
the  hyperemic  nerve  centers.  Ice  bags  should  be  applied  to 
the  head  and  nucha,  and  maintained  there  as  long  as  there  is  no 
chilliness  produced,  and  there  is  some  relief  experienced  from 
the  intensity  of  pain.  Cold  may  be  applied  also  along  the 
dorsal  and  lumbar  vertebra,  in  severe  cases,  as  well  as  to  the 
head  and  neck. 

The  sick  room  should  be  kept  very  quiet,  and  the  number  of 
attendants  reduced  to  the  minimum.  All  noises  intensify  the 
cephalalgia,  and  too  many  people  about  only  aggravate  the 
nervousness,  which  is  already,  in  many  cases,  extreme.  In  the 
way  of  internal  treatment,  Dr.  J.  Lewis  Smith  recommends 
very  highly  the  use  of  bromide  of  potassium.  He  says  it  has 
been  proven  by  experiment  that  it  causes  contraction  of  the 
minute  vessels  of  the  nervous  centers,  so  as  to  diminish  the 
hyperemia,  and  at  the  same  time  it  diminishes  in  a  marked  de- 
gree the  reflex  irritability  of  the  spinal  cord,  two  of  the  most 
beneficial  and  important  effects  of  its  use  in  this  disease. 

In  ordinary  cases,  not  attended  by  eclampsia  or  symptoms 
which  show  that  eclampsia  is  threatening,  he  gives  four  grains 
every  two  hours  to  a  child  of  two  years,  and  six  grains  to  a  child 
of  five  years.  If  eclampsia  occurs,  the  bromide  should  be  given 
more  frequently,  as  every  five  or  ten  minutes,  till  it  ceases.  He 
gives  the  crude  drug,  dissolved  in  simple  cold  water.  He  states 
that  he  has  rarely  observed  bromism  in  children  who  have  re- 
ceived these  doses,  and  never  to  the  extent  of  doing  any  serious 
harm.  This  drug  would  seem  to  be  quite  homeopathic  to 
cerebro-spinal  fever,  for  a  toxic  dose  of  it  produces  exactly  the 
symptoms  we  see  exhibited  in  a  typical  case  of  this  disease, 
viz.,  muscular  weakness,  dilated  pupils,  with,  perhaps,  impaired 
vision,  unsteady  gait,  nausea  or  vomiting,  and  abdominal  pains. 
It  would  be  difficult  to  find  a  drug  whose  pathogenesis  presents 
a  clearer  picture  than  this  of  the  acute  stage  of  cerebro-spinal 
fever. 

Ergot  is  another  important  remedy,  whose  action,  however, 
is  more  physiological  than  homeopathic.  It  perhaps  need  not 
be  excluded  from  our  armamentaria  on  this  account.  Ergot 
has  a  remarkable  power  over  the  circulation,  contracting  the 


614  THE  DISEASES  OF  CHILDREN. 

arterioles  and  diminishing  the  flow  of  arterial  blood.  It  may  be 
given  in  the  fluid  extract,  tincture  or  wine  of  ergot.  Where 
there  is  irritability  of  the  stomach,  or  inability  to  swallow,  it 
may  be  given  conveniently  in  the  form  of  ergotin,  which  is  the 
alkaloid  to  which  the  beneficial  effects  of  secale  cornutum  are 
due.  This  may  be  given  hypodermically,  dissolved  in  water 
with  glycerin. 

The  dose  for  a  child  two  years  old  is  -^^  of  a  grain.  Of  the 
fluid  extract  of  ergot,  the  dose  for  an  infant  is  one  to  three  drops 
in  water,  equal  parts.  Gelsemium  in  first  dilution,  is  another 
valuable  remedy,  and  so  are  aconite  and  belladonna.  When 
eclampsia  is  present  or  threatening,  cuprum  must  not  be  for- 
gotten, nor  zincum.  Glonoin,  from  the  intensity  of  its  symp- 
toms, especially  those  of  the  brain,  should  make  it  a  remedy  of 
prime  value.  Besides  these  drugs,  consult  hyoscyamus,  helle- 
bore, stramonium,  opium,  and  veratrum  viride.  Great  watch- 
fulness should  be  exercised  during  convalescence  to  prevent 
exacerbations.  Study  and  all  mental  excitement  should  be 
strictly  prohibited  until  some  time  after  full  recovery.  As  bad 
sanitary  conditions  are  credited  with  being  conducive  of  the 
disease,  these  must  be  remedied,  and  the  patient  provided  with 
well-ventilated  rooms,  and  given  plenty  of  fresh  air  and  food. 
When  paralysis  ensues,  it  must  be  treated  the  same  as  when 
occurring  from  other  causes. 


CHAPTER  II. 

INFANTILE  TYPHOID  FEVER. 

Synonyms.  —  Enteric  Fever  ;  Infantile  Remittent  Fever ; 
TypJioMalarial  Fever  ;  Typhus  Abdominalis  ;  Continued  Fever. 

Definition. — According  to  the  best  authorities,  the  definition 
of  typhoid  fever  is,  an  acute  infectious  disease,  lasting  from  ten 
to  twenty  days,  or  longer,  characterized  by  gastro-intestinal 
catarrh,  febrile  movement  of  continued  type,  marked  prostra- 
tion, rapid  wasting,  mild  nervous  symptoms,  and,  in  a  certain 
proportion  of  cases,  a  scanty  and  scattered  eruption  of  rose- 
colored  spots,  which  disappear  on  pressure  and  are  developed 
in  successive  crops. 

But  the  folly  of  considering  and  treating  disease  by  name,  is 
nowhere  better  illustrated  than  in  the  fevers  which  are  so  com- 
mon in  early  life,  the  symptoms  of  which  are  in  many  cases 
totally  unlike  those  ascribed  to  typhoid  fever  in  adult  life. 

A  typical  case  of  typhoid  in  the  adult  is  almost  unmistakable. 
No  other  disease  runs  a  more  regular  course.  The  prodromal 
symptoms  are  very  significant.  The  mental  state  is  not  like 
that  of  any  other  fever.  The  tenderness  over  the  ileo-cecal  re- 
gion is  usually  pronounced.  The  temperature  curve  alone  is 
almost  pathognomonic.  From  start  to  finish  the  disease  is  ac- 
companied with  signs  of  fairly  plain  significance.  But  this  is 
not  the  case  with  infantile  typhoid.  In  early  life — that  is  to 
say,  under  ten  or  twelve  years  of  age — the  disease  does  not  ex- 
hibit those  clearly  defined  symptoms  that  characterize  it  in 
after  years. 

For  example,  a  child  is  taken  ill  and  has  fever;  the  fever  re- 
mits in  the  morning,  and  increases  at  night ;  there  is  anorexia, 
headache,  nausea,  nervousness,  perhaps  delirium  ;  the  tongue 
becomes  dry  and  furred  down  the  center  ;  the  bowels  are  at 
first  constipated,  then  loose ;  the  fever  continues  day  after  day, 
with  the  same  morning  remission,  the  same  evening  exacerba- 
tion ;  there  is  more  or  less  meteorism,  and  the  surface  over  the 
bowels  is  sensitive  to  the  touch.     But  is  this  typhoid? 

There  are  no  rose-colored  spots ;  no  regular  gradation  of 
temperature ;  no  swelling  of  cervical  glands,  no  symptoms  of 
pneumonia,  and  there  is  no  indication  of  scrofulosis  or  tuber- 
culosis.    The   only   objective  sign  of  unmistakable  import   is 

(615) 


616  THE  DISEASES  OF  CHILDREN. 

persistent  fever.  This  symptom  continues  with  some  modifica- 
tions and  variations  for  days,  or  even  weeks,  until  at  last,  after 
great  loss  of  strength  and  flesh,  we  find  a  subnormal  tem- 
perature, lasting  for  several  days,  a  slow  return  of  appetite,  a 
gradual  renewal  of  health  and  strength,  and,  after  a  tedious 
convalescence,  the  child  is  quite  well  again. 

But  was  this  a  case  of  typhoid  fever?  The  difficulty  has 
long  been  a  puzzling  one.  It  has  led  some  German  authorities 
• — Lebert  among  others — to  adopt  the  term  "  infective  ^^j/r//w," 
for  febrile  attacks  of  this  kind.  Certain  English  authors  have 
attempted  to  bridge  over  the  difficulty  by  employing  the  still 
looser  expression,  ^^ gastric  fever ^  It  may  be  repeated  that 
typhoid  fever,  as  seen  in  infancy  and  early  childhood,  does  not 
present  those  clearly-defined  symptoms  which  characterize  the 
affection  in  adult  life.  Indeed,  it  holds  so  loosely  to  the  type, 
that  the  landmarks  are  practically  lost.  The  use  of  the  term 
"  typhoid  "  under  any  circumstances,  regardless  of  age,  is  a 
misnomer,  and  is  open  to  serious  objection.  It  presupposes 
that  a  more  or  less  close  relationship  exists  between  it  and 
typhus,  when  in  reality  no  such  relationship  exists.  The  use 
of  the  term  enteric  fever  in  this  connection  is  equally  objection- 
able, for  the  very  good  reason,  that  in  children  there  is  no  con- 
stant abdominal  lesion  attendant  upon  the  disease,  as  there  is  in 
adults,  and  so  we  have,  under  the  nomenclature,  an  enteric 
fever  without  any  enteric  involvement. 

Infantile  remittent  does  not  quite  cover  the  requirements  of 
the  case,  because  all  fevers  of  infancy  are  subject  to  remissions 
and  exacerbations,  and  the  use  of  the  term  is  at  best  so  indefi- 
nite that  it  is  fast  becoming  obsolete. 

Retaining  the  term  typhoid,  however,  we  shall  include  under 
this  head  all  of  those  fevers  of  childhood  of  an  infectious 
nature  and  continued  type,  charging  up  this  indefiniteness  of 
characterization  to  the  versatility  and  inaccuracy  of  the  disease 
itself.  Continued  fever,  unless  due  tq  subacute  and  protracted 
entero-colitis,  is  rare  in  infancy,  but  becomes  more  and  more 
prevalent  from  five  to  six  years  of  age  upward. 

Etiology. — From  what  has  just  been  said,  it  must  be  apparent 
that  no  one  cause  can  obtain  in  all  cases  of  the  disease.  Even 
in  those  cases  which  are  unmistakably  specific  in  character — 
with  enteric  involvement,  typical  temperature,  rose-spots  and 
bronchitis — the  direct  cause  is  in  many  cases  doubtful.  The 
disease,  even  in  adults,  is  only  mildly  contagious,  and  then 
only  through  the  medium  of  the  evacuations.  It  is  undoubt- 
edly spread  by  means  of  contaminated  drinking  water,  milk 
and  possibly  ice.  Among  the  causes  which  are  worthy  of  men- 
tion in  this  connection  are  breathing  impure  air  from  sewers» 


INFANTILE   TYPHOID  FEVER.  617 

cesspools  or  cellars  containing  decaying  vegetables.  But 
these  causes  abound  so  frequently  without  producing  typhoid 
fever  that  they  must  be  regarded  as  predisposing  rather  than 
direct  causes.  Changing  residence  from  country  to  city  has 
frequently  been  noted  as  a  conducing  cause,  age  and  other 
circumstances  being  also  considered.  To  our  mind,  the  anto- 
genetic  origin  of  typhoid  fever  has  never  received  the  consider- 
ation which  it  is  entitled  to.  Mention  has  already  been  made 
of  the  fact  that  certain  German  authorities  speak  of  the  disease 
as  infective  gastritis,  meaning,  as  we  take  it,  that  the  system  is 
infected  or  poisoned  by  its  own  perverted  secretions.  When 
we  consider  the  miles  upon  miles  of  lymphatic  canals,  and  the 
infinite  multitude  of  large  and  minute  lymphatic  glands,  all  of 
which  are  essential  to  the  proper  and  orderly  conduct  of  the 
machinery  of  life,  and  that  their  free  and  unembarrassed  func- 
tion is  absolutely  necessary  to  carry  away  the  products  of  de- 
composition and  decay,  as  well  as  to  furnish  the  material  for 
the  "  renewal  of  life,"  it  is  doing  no  violence  to  logic  or  to  the 
science  of  physiology  to  suppose  that  these  living  sewers,  these 
vital  emunctories,  may  become,  under  certain  circumstances, 
carriers  of  filth  and  promoters  of  disease. 

What  is  true  of  typhoid  is  also  and  equally  true  of  those 
pseudo-typhoids  which  are  equally  or  even  more  common  in 
early  life,  and  for  which  no  better  appellation  has  been  found 
than  continued  fever.  In  all  cases  the  organism  has  become 
infected,  either  from  within  or  from  without,  and  the  phenom- 
enon of  fever  is  nature's  method  of  disposing  of  the  infection — 
a  sort  of  cremation  of  morbid  products  and  unworthy  materials. 

Symptoms  and  Course. — The  fever  is,  generally  speaking,  in- 
sidious in  its  onset,  being  rarely  inaugurated  by  the  chill 
which  characterizes  its  commencement  in  the  adult.  Older 
children  may  experience  chilliness,  or  even  a  distinct  rigor,  but 
only  in  severe  and  exceptional  cases.  Headache  and  loss  of 
appetite  are  among  the  early  symptoms,  perhaps  accompanied 
with  occasional  vomiting.  During  the  day  there  may  be  but 
few  symptoms,  and  those  of  indefinite  type,  such  as  languor, 
dullness,  or  fretfulness,  though  symptoms  of  fever,  with  weak 
pulse  and  dry  skin,  are  not  wanting  to  careful  observation. 
Towards  evening  the  face  becomes  flushed,  or  a  red,  burning 
spot  surmounts  one  cheek  like  a  hectic  glow,  the  headache  is 
intensified,  the  lips  become  red,  and  the  tongue  dry.  The 
child's  sleep  is  restless  and  disturbed  by  mild  delirium.  As 
morning  approaches  the  fever  subsides,  the  sleep  becomes 
more  quiet  and  hopes  are  entertained  of  speedy  recovery. 

Day  after  day  the  same  history  is  repeated.  The  febrile 
movement  becomes  more  pronounced  as  the  disease  progresses. 


618  THE  DISEASES  OF  CHILDREN. 

the  morning  remission  and  the  evening  exacerbation  continue, 
until  after  a  time,  the  abdomen  becomes  tumid,  the  spleen 
is  enlarged,  diarrhea  sets  in,  and  the  child  becomes  rapidly 
emaciated.  Somewhere  between  the  sixth  and  the  twelfth  day, 
in  the  majority  of  cases,  the  rose-colored  eruption  appears.  In 
some  cases,  the  number  of  spots  is  less  than  half  a  dozen.  They 
are  widely  scattered  over  the  abdomen,  disappear  on  pressure, 
and  reappear  slowly  when  the  pressure  is  removed.  They  ap- 
pear in  successive  crops,  each  crop  remaining  visible  for  two  or 
three  days.  The  headache,  which  is  more  or  less  prominent  in 
the  initial  stage  in  the  majority  of  cases,  ceases  as  the  disease 
becomes  established.  Epistaxis  occurs  occasionally  during  the 
first  week,  but  is  not  abundant  nor  troublesome.  A  mild  bron- 
chitis is  nearly  always  present,  with  accelerated  breathing,  and 
more  or  less  cough.  This  is  usually  not  developed  until  the 
second  week  of  the  fever.  Abdominal  tenderness,  especially 
on  the  right  iliac  region,  is  often  present,  but  must  not  be  mis- 
taken for  the  hyperesthesia  which  is  common  to  all  fevers  in 
children,  and  which  is  observed  especially  over  the  abdomen, 
chest  and  inner  portions  of  the  thighs. 

The  temperature  in  infantile  typhoid  is  subject  to  great  and 
singular  variations.  The  remissions  often  present  no  regularity 
from  day  to  day  in  the  time  of  their  occurrence.  If  the  tem- 
perature be  taken  every  two  or  three  hours,  it  will  show  a 
remarkable  irregularity,  sometimes  running  up  and  down  several 
times  in  the  course  of  twenty-four  hours.  The  acme  may  be 
reached  at  any  hour,  but  there  is  a  tendency  to  the  occurrence 
of  two  distinct  exacerbations,  one  at  about  four  o'clock,  and 
the  other  at  nine  o'clock  P.  M.  But  there  is  no  stated  regular- 
ity about  it.  The  pulse  is  apt  to  follow  the  temperature  quite 
closely  in  its  rise  and  fall,  but  exceptions  to  this  rule  are  nu- 
merous. It  is  not  uncommon  in  this  disease  to  have  a  tempera- 
ture of  103°  Fahr.,  or  even  higher,  and  a  pulse  considerably 
under  120. 

On  the  other  hand,  the  pulse  may  be  as  rapid  as  1 50  or  more, 
and  recovery  take  place.  In  some  cases,  the  rhythm  and  the 
force  of  the  pulse  is  much  disturbed,  and  may  even  be  dicrotic, 
but  a  dicrotic  pulse  in  childhood  is  much  more  rare  than  in  adult 
life.  Diffuse  bronchitis  and  broncho-pneumonia  occur  as  com- 
plications in  a  certain  proportion  of  cases.  In  the  majority  of 
instances,  the  bronchitis  is  of  moderate  intensity,  and  ceases  as 
soon  as  the  fever  has  spent  its  force. 

Hypostatic  congestion,  due  to  position  and  feeble  circulation, 
is  by  no  means  uncommon.  It  is  usually  limited  to  the  pos- 
terior portions  of  the  chest  and  the  bases  of  the  lungs. 

Symptoms  indicative  of  disturbance  of  the  digestive  organs 


INFANTILE   TYPHOID  FEVER.  619 

are  practically  the  same  as  in  adults.  There  is  generally  but 
little  desire  for  food  during  the  progress  of  the  fever,  and  thirst 
is  easily  satisfied.  When  convalescence  begins,  however,  the 
appetite  is  ravenous  and  difficult  to  control.  As  a  rule,  the 
tongue  is  red  at  the  edges  and  tip,  and  is  covered  in  the  center 
with  a  pasty,  yellowish-white  fur,  which  in  the  course  of  the 
disease  gives  way  to  a  smooth,  bright-red  and  varnished  look. 
Sordes  on  the  teeth  and  gums  are  not  common  in  childhood. 
The  lips  are  apt  to  become  cracked  and  fissured,  and  covered 
with  superficial  crusts.  Aphthous  ulcerations  also  occur  on  the 
tongue  and  at  the  corners  of  the  mouth.  The  condition  of  the 
bowels  is  extremely  variable.  In  the  commencement  of  the 
attack  constipation  is  the  rule.  In  its  later  course  there  is  a 
marked  tendency  to  diarrhea,  the  number  of  passages  varying 
from  two  or  three  to  ten  or  more  in  the  twenty-four  hours. 
The  stools  are  apt  to  show  the  well-known  appearance  of  thick 
pea-soup,  and  divide,  upon  standing,  into  an  upper,  cloudy,  quite 
liquid  layer,  and  a  lower  stratum  composed  of  greenish-yellow 
masses.  Except  in  the  case  of  very  young  infants,  the  evacu- 
ations are  under  the  control  of  the  will.  In  very  severe  and 
critical  cases  only  do  they  become  involuntary. 

Intestinal  hemorrhage  is  rare  in  infancy  and  childhood,  al- 
though in  exceptional  cases  it  does  occur.  The  late  Dr.  Earle, 
of  this  city,  had  a  case  of  fatal  hemorrhage  in  an  infant  twenty- 
two  months  old.  Post-mortem  examination  revealed  the  char- 
acteristic lesions  of  enteric  fever.  The  spleen  is  very  generally 
enlarged,  although  probably  not  more  so,  and  no  more  fre- 
quently than  in  other  acute  infectious  diseases.  In  cases  in 
which  the  fever  runs  unusually  high,  the  spleen  is  apt  to  be  in- 
volved early  in  the  course  of  the  disease  ;  but  pain  over  the 
spleen  is  rare,  and  the  enlargement  of  this  organ  begins  to  sub- 
side with  defervescence.  It  has  been  noticed  in  cases  of  relapse 
that  the  spleen  continues  enlarged  during  the  interval  between 
the  primary  attack  and  the  relapse. 

The  nervous  symptoms  in  infantile  typhoid  fever  are  not  sa 
pronounced  as  is  the  case  with  adults.  Headache  is  common 
as  a  prodromal  symptom,  and  is  so  especially  at  night,  dur- 
ing the  first  week  of  the  disease.  The  delirium  is  generally 
moderate  and  mild,  and  confined  generally  to  the  night-time, 
and  is  sometimes  associated  with  night  terrors.  It  is  transient 
and  recurrent,  rather  than  continuous,  and  of  the  type  known 
as  wandering  delirium.  In  very  young  infants  delirium  is  apt 
to  be  replaced  by  sudden,  sharp  and  prolonged  outcries.  In 
older  children  we  have  the  same  character  of  delirium  as  in 
adults.  Twitching  of  the  muscles  of  the  face  and  hands — the 
so-called  subsultus  tendinum — is  common,  but  plucking  at  the 


620  THE  DISEASES  OF  CHILDREN. 

bedclothes,  even  in  the  worst  cases,  is  rare  in  children.  Enteric 
fever  differs  from  scarlatina  in  the  extremely  rare  occurrence 
of  acute  nephritis  as  a  sequel.  It  is  said  that  menstruation  in 
girls  at  puberty  is  apt  to  be  profuse  and  prolonged.  In  some 
cases,  however,  it  is  very  scanty,  or  postponed  until  conva- 
lescence is  fully  established.  Enteric  fever  does  not,  during  its 
course,  confer  any  immunity  from  the  ordinary  diseases  of 
childhood.  If  anything,  the  reverse  is  true.  Instances  are  re- 
corded wherein  measles  and  scarlatina  have  either  preceded  or 
followed  the  disease,  or  have  co-existed — the  eruptions  merging 
the  one  into  the  other. 

Duration. — The  duration  of  enteric  fever  in  childhood  is  very 
variable.  Many  cases  last  only  ten  or  twelve  days,  while  others 
last  twice  as  long.  It  is  probable  that  in  many  instances  the 
fever  has  been  in  progress  for  several  days  before  attention  has 
been  attracted  to  it.  In  some  cases  doubtless  the  primary 
fever  is  overlooked  altogether,  and  the  physician  is  called  only 
at  the  time  of  relapse. 

Diagnosis. — If  we  attempt  to  discriminate  between  true 
typhoid  fever,  as  it  occurs  in  infancy,  and  that  other  form 
which  is  much  more  common,  and  in  which  there  is  no  evidence 
during  life  of  any  enteric  lesion — the  simple  continued  fever 
of  some  authors — we  shall  have  to  be  very  exact  in  our  obser- 
vations and  very  expert  in  our  examinations.  It  is  much  easier 
to  exclude  such  diseases  as  the  eruptive  fevers,  malarial  fevers 
and  acute  tuberculosis.  The  latter  especially  presents  many 
symptoms  that  might  lead  to  confusion.  The  insidious  onset 
is  the  same  in  both  diseases,  and  the  temperature  is  subject  to 
the  same  oscillations ;  vomiting  is  often  seen  in  the  early  stage 
of  typhoid,  as  well  as  in  tuberculosis,  and  in  the  latter  affection 
diarrhea  is  by  no  means  uncommon.  Only  careful  observation 
continued  for  quite  a  period  of  time  will  suffice  to  distinguish 
one  from  the  other.  It  is  sometimes  a  very  diflficult  matter  to 
distinguish  typhoid  from  meningitis.  The  frontal  headache  is 
common  to  each,  so  are  muscular  tremors,  and  in  meningitis  of 
tubercular  origin  there  may  be  pleurisy,  bronchitis  or  even  some 
evidence  of  local  consolidation.  In  the  latter  disease,  however, 
there  is  likely  to  be  intolerance  of  light,  and  the  temperature 
is  not  usually  as  high  as  in  typhoid  fever.  Sub-acute  enteritis 
or  entero-colitis  has  many  features  that  simulate  typhoid,  but 
in  the  latter  there  is  bronchitis  and  cough,  while  in  the  inflam- 
mation these  are  wanting.  There  is  absent  also  the  headache, 
epistaxis  and  delirium  ;  nor  are  there  any  rose  spots.  Should 
there  be,  or  have  been,  other  cases  of  typhoid  fever  in  the 
house  or  family,  this  fact  would  materially  aid  in  clearing  up 
the  diagnosis. 


INFANTILE   TTPHOID  FEVER.  621 

Treatment. — A  case  of  fever,  such  as  we  have  been  consider- 
ing, may  be  of  all  grades  of  severity.  As  we  have  seen,  many 
cases  are  atypical.  In  some  the  bowels  are  slightly  or  seriously 
implicated  ;  in  others,  not  at  all.  It  would  be  manifestly  ab- 
surd, under  such  circumstances,  to  treat  all  cases  alike,  or  to 
expect  that  any  one  remedy  can  be  of  universal  efficacy,  either 
to  abort  the  fever  or  modify  its  course.  There  is  no  such 
remedy  known.  Each  case  must  be  individualized  and  treated 
symptomatically.  Sometimes  a  single  symptom  may  stand 
out  with  such  prominence  as  to  point  to  the  appropriate  drug, 
but  more  often  the  totality  of  the  symptoms  will  afford  a  better 
guide. 

The  fact  must  not  be  forgotton  that  water  is  the  great  anti- 
pyretic. By  its  judicious  use  the  intensity  of  the  fever  can  be 
materially  abated,  and  when  the  nervous  symptoms  are  promi- 
nent, water  is  wonderfully  tranquilizing.  We  have  no  words 
but  those  of  censure  for  that  heroic  hydropathy  that  plunges  a 
fever  patient  into  a  bath  of  68°  Fahr.  or  lower,  and  repeats  the 
shock  every  two  or  three  hours.  Such  a  procedure  is  danger- 
ous in  the  extreme.  But  the  entire  body  may  be  sponged  over 
with  tepid  water,  or  water  and  alcohol,  once  a  day,  or  oftener 
if  the  temperature  runs  high,  and  with  excellent  results. 

Where  defervescence  is  tardy,  and  the  skin  is  devoid  of  per- 
spiration, the  wet-sheet  pack,  given  as  directed  in  our  intro- 
ductory chapter,  will  be  preferable  to  the  sponge  bath. 

The  diet  of  these  patients  is  of  the  greatest  importance. 
Where  fresh  milk  is  used,  it  should  be  boiled  and  strained, 
and  then  may  be  given  either  cold  or  hot,  whichever  is  pre- 
ferred. 

Where  the  stomach  is  irritable,  or  milk  does  not  agree, 
koumiss  or  buttermilk  may  be  substituted.  Barley  water,  or 
weak  mutton  broth,  is  permissible  with  older  children,  but  beef 
tea  and  chicken  broth  are  not  suitable  for  any  cases.  Starchy 
foods  should  be  avoided,  for  the  secreting  powers  of  the  sali- 
vary glands  and  also  the  pancreas  are  often  seriously  impaired. 
During  convalescence  great  care  must  be  exercised  lest  the 
weakened  digestive  organs  be  overtaxed.  At  this  time  the 
food  should  consist  of  easily  digested  articles,  such  as  bread 
and  butter,  light  puddings,  custard  and  meat  broths ;  but  solid 
food  ought  not  to  be  eaten  until  the  temperature  has  been 
normal  for  a  week  or  more. 

Internal  Treatment — Arsenicum. — Probably  this  remedy  is 
called  for  in  a  greater  number  of  cases  than  any  other.  The 
more  serious  the  case,  speaking  in  a  general  way,  the  more  ap- 
propriate is  its  selection.  It  may  not  be  needed,  as  Prof.  Kip- 
pax  remarks,  in  the  early  stage  of  the  fever ;  but  sooner  or  later 


622  THE  DISEASES  OF  CHILDREN. 

its  symptomatology  will  indicate  that  it  covers  a  larger  field  of 
symptoms  than  any  other  one  drug. 

Dr.  Thomas  Nichol  says  of  arsenicum :  "  In  the  most  dis- 
heartening cases,  cases  which  seem  to  be  utterly  hopeless,  when 
the  vital  functions  are  in  the  grasp  of  a  morbid  poison  of  the 
most  malignant  kind,  and  the  very  life-blood  is  profoundly  and 
completely  altered,  then,  this  great  remedy  is  capable  of  saving 
life." 

It  is  rarely  indicated  when  both  body  and  mind  are  tranquil, 
for  restlessness,  with  anxiety,  is  one  of  its  most  prominent  key- 
notes. 

In  the  arsenicum  typhoid  case,  the  heat  of  the  skin  is  dry  and 
burning  ;  the  patient  calls  for  water  often,  but  drinks  little  at  a 
time  ;  the  head  throbs  violently  with  pain  ;  desire  to  throw  off 
the  bed  covering  \  great  restlessness.  The  pulse  is  small  and  weak, 
or  possibly  irregular  and  intermittent ;  exhaustion  both  of  body 
and  mind.  Even  early  in  the  progress  of  the  disease  there  are 
evidences  of  decomposition  of  the  fluids  of  the  body ;  the  odor 
of  the  stools  is  very  foul  and  there  is  a  fetid  odor  to  the  patient's 
breath  ;  the  nosebleed  is  ichorous.  Delirium  is  attended  with 
tremulousness,  and  at  night  is  often  violent.  The  features  are 
greatly  changed  ;  there  is  a  pale,  yellow,  cachectic  look,  often 
livid  or  lead-colored.  The  eyes  are  dull,  glazed  and  sunken  ; 
the  lips  dry  and  fissured.  The  stomach  is  tender  to  external 
pressure  ;  spleen  is  swollen  and  painful ;  there  is  marked  swell- 
ing and  distension  of  the  abdomen.  There  are  sounds  of  mov- 
ing flatus  and  liquids  in  the  intestines.  Deafness,  with  ringing 
in  the  ears  and  head.  The  evacuations  are  exhaustive  ;  stools 
watery,  small  and  yellowish,  or  greenish-brown  and  acrid.  The 
urine  is  scanty  and  turbid  ;  rapid  emaciation  ;  edematous  swell- 
ing of  the  feet ;  circumscribed  redness  of  one  or  both  cheeks ; 
involuntary  urination  ;  very  tenacious  mucus  in  the  chest  {tartar 
emetic,  kali  bich.) ;  extensive  pulmonary  hypostasis,  symptoms 
worse  from  i  to  3  A.  M. 

Acid  Nitricum. — This  remedy  is  chiefly  indicated  in  the  ad- 
vanced stage,  where  the  abdominal  lesion  has  become  pro- 
nounced ;  marked  tenderness  of  the  abdomen,  especially  in  the 
ileo-cecal  region ;  gurgling  on  pressure,  with  blood-streaked 
diarrheic  stools,  which  are  foul-smelling,  brownish,  pasty  or 
slimy.  The  tongue  is  smooth,  glossy  and  deep  red.  The  men- 
tal stage  is  irritable  and  excitable.  Pulse  irregular,  and  inter- 
mits Qvery  fourth  beat  (third  beat  muriatic  acid).  Emaciation, 
especially  of  the  arms  and  thighs.     (Kippax.) 

Acid  Muriaticum. — Hughes  ranks  this  remedy  with  arseni- 
cum as  one  of  the  remedies  against  the  essential  lesion  of  ty- 
phoid.     It  is  the    great    remedy,    not  only   when    putridity 


INFANTILE   TTPHOID  FEVER.  623 

threatens  to  set  in,  but  also  when  it  is  fully  developed.  The 
stools  are  frequent,  foul  and  scanty,  often  blood-streaked,  and 
the  discharges  are  mingled  with  shreds  of  intestinal  mucous 
membrane,  and  fragments  of  whitish  mucus.  The  patient  is 
extremely  weak.  The  patient  is  constantly  settling  down  in 
bed ;  stupor,  with  perfect  indifference  to  surrounding  events. 
The  abdomen  is  swollen  and  tender,  and  the  sphincter  ani  is 
partially  paralyzed.  The  breath  is  very  offensive,  and  the  mu- 
cous membrane  of  the  mouth  is  ulcerated  in  patches  (stoma- 
titis). Delirium  continues.  Glistening  eyes,  contracted  pupils ; 
hypersensitiveness  to  sounds.  Excessive  dryness  of  lips,  mouth 
and  tongue.  Profuse  discharge  of  clear,  acid  urine.  Pulse 
rapid  and  feeble,  intermits  every  third  beat.  Respiration  ac- 
celerated. 

Baptisia. — The  time  is  not  far  away  since  baptisia  was  re- 
garded by  the  great  majority  of  homeopathic  physicians  as 
the  sheet  anchor — the  sine  qud  non — for  the  successful  treat- 
ment of  typhoid  fever.  The  remedy  has  become  indissolubly 
linked  with  the  disease,  but  the  claims  which  were  once  made 
for  its  curative  powers  have  been  much  modified  by  clinical 
experience.  It  is  undoubtedly  the  remedy  par  excellence  dur- 
ing the  first  week.  After  that,  if  the  disease  is  not  aborted, 
there  are  other  drugs  possessing  far  more  efficacy.  Dr.  Kippax 
says,  speaking  of  baptisia :  '*  It  is  capable  of  exciting  a  fever 
resembling  that  of  typhoid,  and  of  producing  congestion  and 
catarrhal  inflammation  of  the  intestinal  mucous  membrane, 
with  abdominal  tenderness  and  diarrhea,  the  pathological  con- 
dition present  during  this  period,"  the  first  week. 

Other  remedies,  however,  besides  baptisia,  are  capable  of 
doing  the  same  thing,  and  it  is  only  by  noting  the  minutest 
shades  of  difference,  that  we  can  properly  affiliate  the  drug  to 
the  disease.  The  baptisia  patient  feels  chilly  all  day,  and  hot 
at  night ;  chilliness  and  soreness  of  the  whole  body,  with  intol- 
erance of  pressure  on  lying.  The  pulse  is  full,  soft  and  quick. 
The  tongue  is  dry  and  red,  swollen  and  thick.  The  stools  are 
very  fetid,  and  so  is  the  patient's  breath.  Indeed, /"^//d^zV;/ is 
one  of  the  prime  characteristics  of  this  drug.  The  mental  state 
of  the  baptisia  patient  is  another  peculiarity  that  will  serve  to 
distinguish  it  from  its  congeners. 

There  is  great  nervous  restlessness ;  heavy  sleep  with  fright- 
ful dreams,  or  "  the  patient  cannot  go  to  sleep  because  she  can- 
not get  herself  together ;  her  head  feels  as  if  scattered  about, 
and  she  tosses  about  the  bed  to  get  the  pieces  together,"  or 
"  feeling  as  if  the  lower  limbs  were  severed  from  the  body ; 
sensation  as  of  a  second  self  alongside  in  bed  "  {bell.).  Falls 
asleep  in  the  midst  of  attempted  conversation.     Confusion  of 


624  THE  DISEASES  OF  CHILDREN. 

ideas.  The  mental  state  and  fetidity  of  all  the  secretions  are 
the  marked  characteristics  of  baptisia. 

Bryonia. — This  remed}'  is  also  chiefly  indicated  in  the  early 
stages.  It  is  especially  valuable  when  bronchitis  or  pulmonary 
congestion  complicates  the  fever.  The  bryonia  patient  is 
exceedingly  irritable,  and  easy  to  take  offense.  Violent,  op- 
pressive, stupefying  headache.  Feels  better  from  lying  down  ; 
wants  to  go  home.  Buzzing  in  the  ears,  with  hardness  of 
hearing.  Face  red,  hot  and  puffy.  Excessive  thirst  for  large 
quantities  of  water.  Dark,  almost  brown,  urine.  Bleeding 
from  the  nose  after  rising  or  during  sleep.  The  tongue  is  at 
first  white  or  yellowish,  but  soon  becomes  dry,  rough  and  dark 
in  color.  Cannot  sit  up  from  nausea  and  dizziness.  Dr}-, 
hacking  cough,  with  stitches  in  the  region  of  the  chest  and 
liver.  Pain  in  the  back  and  limbs  when  moving.  Epigastric 
region  painful  to  touch  and  pressure. 

Patient  is  obliged  to  He  perfectly  quiet,  because  the  slightest 
motion  causes  nausea  ;  vomiting  with  nausea  on  waking  in  the 
morning.  At  the  commencement  of  the  fever  chilliness  and 
heat  alternate,  but  later  on  the  heat  is  intense  and  almost  con- 
tinuous. Dr.  Nichols,  discussing  the  dubious  question  of  the 
possibility  of  aborting  typhoid  fever,  quotes  Dr.  Fornils,  of 
Philadelphia,  as  saying :  '"I  think  that  if  any  abortive  power 
can  be  ascribed  to  any  drug  here,  bryonia  has  it ;  its  success 
will  depend  on  its  early  application,  a  thing  not  always  possi- 
ble, as  we  are  generally  called  too  late.  I  am  not  an  enthusiast, 
but  I  have  seen  this  drug  work  marvels,  subduing  the  gastric 
irritation,  cleansing  and  moistening  the  tongue,  healing  the 
cracks,  and  enabling  the  stomach  to  retain  hquid  food,  dimin- 
ishing and  changing  the  color  of  the  stools,  and  finally  bringing 
the  whole  condition  to  a  favorable  turn.'  "  Nichols,  for  himself, 
says  :  "  Formerly  I  believed  that  no  remedy  could  materially 
change  or  shorten  this  disease,  but  now  I  am  of  the  opinion 
that  the  homeopathically  indicated  remedy  can  change  the  type 
of  fever  from  the  normal  to  the  mild  or  abortive  ;  but  in  order 
to  effect  this,  you  must  begin  treatment  early,  that  is,  before 
the  disease  is  developed.  And  then  you  can  never  be  quite 
certain  that  it  was  typhoid  fever  you  have  been  treating,  for  in 
mild  or  abortive  cases,  the  pathognomonic  symptoms  are  ab- 
sent. In  my  experience  this  abortifacient  power  has  chiefly 
been  exercised  by  bryonia  and  baptisia."  My  own  experience 
is  in  accordance  with  these  views,  qualified  by  the  remark  that 
typhoid  is  probably  much  more  amenable  to  drug  treatment  in 
early  than  in  mature  life.  While  the  producing  cause  has  virgin 
soil  to  work  upon,  so  has  the  indicated  remedy ;  and  when 
taken  in  time,  that  is  to  say,  before  the  disease  has  had  time  to 


INFANTILE   TYPHOID  FEVER.  625 

complicate  itself,  we  are  able  to  prevent  the  development 
of  those  special  symptoms  which  are  characteristic  of  the 
affection  in  mature  years.  May  this  not  be  the  reason  why 
we  often  lack,  in  infantile  cases,  those  distinctive  signs  of 
typhoid,  nature,  unaided,  being  sometimes  able  to  partially 
or  wholly  prevent  the  full  development  of  the  typhoid 
symptoms  ? 

RJnis  toxicodendron. — The  symptoms  which  indicate  rhus  are 
somewhat  analogous  to  those  of  bryonia,  but  the  patient  is  from 
the  commencement  more  seriously  ill.  In  the  bryonia  case 
there  is  but  little  tendency  to  putridity  of  the  fluids  of  the 
body,  while  in  rhus  patients  this  is  very  marked.  When  rhus 
is  called  for,  the  patient  lies  stupid  and  semi-comatose — so  weak 
that  when  conscious  he  is  unable  to  move.  Watery  diarrhea, 
often  involuntary ;  thin,  watery  epistaxis ;  violent  cough  with 
shortness  of  breath ;  pain  in  the  throat,  as  if  the  tonsils  were 
swollen  ;  slight  perspiration  over  the  whole  body  towards  morn- 
ing ;  bruised  feeling  over  the  whole  body,  with  soreness  in  all 
the  bones  ;  constant  desire  to  lie  down  and  be  quiet.  The  lips 
are  dry  and  bleeding,  and  the  tongue  is  swollen,  dry,  and  brown. 
The  red,  triangular  tip  is  very  characteristic.  Great  thirst  for 
cold  drinks,  especially  cold  milk.  Pale,  sunken  face,  with  dark 
rings  around  the  eyes.  Sordes  on  teeth  and  gums.  Baehr 
says:  "Cases  adapted  to  rhus  never  run  a  speedy  course,  nor 
will  the  crisis  have  to  be  expected  previous  to  the  seventeenth 
day  ;  until  then  the  medicine  will  have  to  be  continued  without 
fear,  unless  some  other  remedy  should  be  indicated  by  particu- 
lar symptoms." 

Belladonna. — This  remedy  is  indicated  in  cases  wherein  there 
is  great  cerebral  congestion.  The  pain  in  the  head  is  exces- 
sive ;  there  is  vertigo,  with  staggering  on  attempting  to  walk. 
The  headache  is  aggravated  by  noise,  shocks,  motion,  or  when 
moving  the  eyes.  The  carotids,  and,  indeed,  all  of  the  cere- 
bral arteries,  beat  and  throb  more  markedly  than  normal ; 
the  patient  is  sleepless,  but  greatly  desires  sleep  ;  frightful  vi- 
sions are  seen  as  soon  as  the  eyes  are  closed;  sighing  during 
sleep;  sudden  awakening  with  a  start  and  fright;  tendency 
to  bury  the  head  in  the  pillow  and  draw  up  the  legs.  The 
pulse  is  hard,  small  and  rapid  ;  face  and  hands  cold  ;  stertor- 
ous respiration;  subsultus  tendinum ;  tendency  to  coma. 
The  delirium  is  furious.  Visions  and  delirious  talk  of  dogs, 
wolves,  mice,  giants  and  fire.  The  child  does  not  know  his 
nearest  friends.  The  diarrhea  is  watery,  profuse  and  painless. 
Perspiration. 

Phosphorus. — This  remedy  is  indicated  in  cases  of  adynamic 
type  and  where  there  is  a  complication  of  bronchitis  and  pneu- 
D.  C— 40 


626  THE  DISEASES  OF  CHILDREN. 

monia.  The  stools  are  painless,  profuse  and  either  resemble 
dirty  water  or  are  black,  like  coffee  dregs. 

Constant  sleepiness  :  contracted  pupils  ;  coma  vigil ;  dullness 
of  hearing  ;  hard,  dry  cough  ;  regurgitation  of  food  ;  loud  rum- 
bling in  the  bowels.  Typhoid  pneumonia. — Hepatization  of  the 
lungs  ;  great  emaciation  ;  epistaxis  ;  involuntary  stools  ;  meteor- 
istic  distension  of  the  abdomen,  with  rumbling  and  gurgling; 
profuse  night  and  morning  sweats ;  burning  in  stomach  ;  low, 
muttering  delirium  ;  small,  quick,  easily  compressed  pulse ; 
regurgitation  of  food  in  mouthfuls  ;  diarrhea,  aggravated  by  eat- 
ing ;  feeling  of  fullness  and  distension  in  stomach,  even  after 
eating  a  very  little. 

Other  remedies  which  should  be  consulted  in  cases  of  this 
kind  are :  argaricus  muse,  apis  me  I,  arutn  triph.,  calcarea 
carb.y  camphor,  carbo  veg.,  cinchona,  colchicum,  gelsemium,  hyos- 
cyamus,  hamamelis,  ignatia,  lycopodiiim,  mercurius,  nux  mos- 
chata,  nux  vomica,  opium.,  Pulsatilla,  silicia,  sulphur,  sulphuric 
acid,  tartar  emetic,  terebinthina,  veratrum  alb.,  veratrum,  viridCy 
zincum. 

The  treatment  during  convalescence  is  all  important.  It 
will  not  do  to  consider  the  patient  as  well  as  soon  as  the  fever 
has  abated.  A  subnormal  temperature  nearly  always  succeeds 
the  period  of  pyrexia,  and  in  the  early  morning  the  thermome- 
ter may  not  register  above  96°  or  97°  Fahr.  The  vitality  is  at 
low  ebb  and  the  greatest  care  is  necessary  in  the  matters  of 
eating,  drinking  and  exercising.  In  cases  where  there  is  great 
prostration,  or  in  which  the  convalescence  is  protracted  from 
weakness,  alcoholic  stimulants  are  permissible  and  useful,  espe-^ 
cially  so  when  the  heart's  action  is  feeble  or  irregular.  Wine- 
whey,  in  very  small  quantities,  regulated  according  to  the  age 
of  the  child,  may  be  given  at  intervals  of  two  or  three  hours. 
It  is  prepared  by  adding  four  ounces  of  sherry  wine  to  eight 
ounces  of  boiling  milk,  and  then  straining  after  coagulation. 
In  sudden  emergencies,  a  little  whisky  toddy  may  be  given, 
i.  e.,  a  tablespoonful  of  whisky  to  four  of  hot  water,  to  which 
a  little  loaf  sugar  is  added.  Vin  Mariani  (cocoa  wine),  is  an 
admirable  wine  for  convalescents,  and  may  be  given  in  very 
small  doses  to  quite  young  infants. 

We  do  not  like  the  California  wines  for  invalids  and  chil- 
dren. They  are  too  heady,  too  alcoholic,  and  do  not  set  well 
on  the  stomach.  Probably  the  best  wine  in  the  world  for  the 
purpose  here  indicated,  is  Lorenz  Reich's  Hungarian  Tokay 
(Tokayer  Ausbruch).  It  is  imported  direct  by  Mr.  Lorenz 
Reich,  of  New  York  City,  especially  for  medicinal  purposes, 
and  is  a  smooth,  rich  and  well-aged  Tokay,  of  absolute  purity, 
neither   acid    nor   oversweet.     No    other    wine,    imported    or 


INFANTILE  TTPHOID  FEVER.  627 

domestic,  has  received  such  unqualified  endorsement  from 
the  highest  professional  authorities  of  all  schools  of  medical 
practice. 

Children  recovering  from  a  continued  fever,  should  not 
be  sent  to  school  until  their  health  and  strength  are  fully  re- 
stored, which  may  be  weeks,  or  in  some  cases  months,  after 
all  fever  has  ceased.  A  sojourn  in  the  country,  for  city-reared 
children,  has  a  very  salutary  effect  in  promoting  a  restoration 
to  health. 


CHAPTER  III. 

INTERMITTENT      FEVER      (MALARIAL     FEVER;      CHILLS      AND 
FEVER  ;  MIASMATIC  FEVER  ;   AGUe). 

Definition.  —  Intermittent  fever  is  an  endemic,  sometimes 
epidemic,  paroxysmal  disease,  each  paroxysm  consisting  of 
a  succession  of  definite  stages,  viz.,  a  cold,  a  hot  and  a  sweat- 
ing stage.  The  paroxysms  are  separated  from  each  other  by 
intermissions  or  apyrexial  periods  of  varying  length,  during 
which  the  patient  enjoys  comparative  health.  According  to 
the  length  of  the  intervals,  the  fever  may  be  of  different  types, 
as  the  quotidian,  the  tertian  and  the  quartan.  There  are  also, 
double  forms,  as  double  quotidian,  double  tertian,  etc. 

Etiology. — Intermittent  fever  is  due  to  malarial  poisoning. 
Its  miasmatic  origin  is  universally  conceded.  The  term  malaria 
is  a  compound  of  two  Italian  words,  tnali,  meaning  evil,  or 
harmful,  and  aria,  air,  and  has  come  to  signify  the  hurtful  and 
disease-producing  emanations  from  marshes  or  decaying  vege- 
tation. The  exact  nature  of  the  poison  or  miasm  is  unknown. 
Certain  requirements  or  factors  are  necessary  to  the  develop- 
ment of  the  morbific  agent.  These  are,  rank  vegetation, 
moisture  and  a  certain  average  degree  of  temperature.  Unless 
all  three  of  these  factors  are  operative  conjointly,  the  poison 
will  not  materialize.  The  average  daily  temperature  must  not 
fall  below  58°  Fahr. ;  there  must  be  an  abundance  of  vegetation, 
and  a  due  amount  of  moisture. 

Malaria  may  enter  the  human  system  either  by  the  respired 
air,  or  through  the  digestive  tract,  with  food  or  drink.  After 
it  has  once  entered  the  organism,  the  period  of  its  incubation 
varies  from  a  few  hours  to  weeks  or  months.  Cases  are  on  rec- 
ord in  which  a  whole  year  has  elapsed  between  the  inhibition 
of  the  poison  and  its  morbific  manifestations.  Other  instances 
have  been  noted  where  a  chill  has  been  experienced  within 
twenty-four  hours  after  sleeping  in  a  malarious  locality.  No 
race  or  nationality  enjoys  complete  immunity  from  its  effects ; 
the  blacks  are,  however,  less  susceptible  to  it  than  the  whites. 

All  periods  of  life,  also,  from  infancy  to  old  age,  are  suscep- 
tible. The  greatest  susceptibility  is  exhibited  between  the 
ages  of  five  and  fifteen  years.  The  weak  and  the  debilitated  are 
more  subject  to  its  influence  than  the  robust.  An  organism 
(628) 


IN  TERM  I T  TEN  T  FE  I  ER.  629 

once  invaded  by  its  pernicious  influence  is  thereby  rendered 
more  liable  to  subsequent  attacks.  A  careful  study  of  the 
physical  conditions  favorable  to  the  development  of  malaria 
shows  that  it  is  most  prevalent  about  marshes,  swamp  lands  and 
damp  bottom  lands.  If  the  low  lands  are  saturated  with  salt 
water  and  subject  to  an  occasional  overflow  of  fresh  water,  the 
conditions  for  the  evolution  of  malaria  are  exceptionally  favor- 
able. 

Cutting  off  timber  from  new  lands  and  exposing  the  damp 
and  half-decayed  vegetation  beneath,  to  the  rays  of  the  sun,  is 
a  very  prolific  source  of  malaria.  The  excavations  in  the  sub- 
urbs about  Chicago,  made  necessary  by  the  laying  out  of  new 
streets,  building  sewers,  placing  cable  tracks,  making  cellars, 
etc.,  etc.,  are  at  the  present  time  giving  rise  to  malarial  diseases 
along  the  line  of  these  improvements.  Personally  considered, 
other  things  being  equal,  all  weakening  influences,  such  as  in- 
creased moisture  of  the  atmosphere,  exposure  to  excessive 
solar  heat,  sudden  cooling  of  the  cutaneous  surface,  and  inordi- 
nate eating  and  drinking,  favor  the  action  of  the  malarious 
influence.  These,  each  and  all,  act  by  disturbing  the  equi- 
librium of  the  body,  and  thus  lowering  the  power  of  resistance. 

There  are  other  conditions,  fortunately,  which  are  inimical 
to  the  production  of  malaria,  among  which  may  be  mentioned 
the  extremes  of  latitude.  Malaria  is  seldom  generated  north 
of  63°  north  latitude  or  south  of  57°  south  latitude.  The 
further  we  recede  from  the  equator  within  these  limits,  the 
more  feeble  becomes  the  malarial  poison.  Again,  malaria  is 
seldom  found  beyond  1,000  feet  above  sea  level ;  an  average 
temperature  below  60°  Fahr.  is  always  and  everywhere  unfavor- 
able to  the  generation  of  malarial  poison.  The  daytime  is  less 
favorable  for  the  development  of  the  miasm  than  is  the  night. 

It  is  said  that  strong  winds  diminish  the  virulence  of  the 
poison,  doubtless  because  they  scatter  it  broadcast,  and  thus 
prevent  its  concentrated  influence.  A  hot  and  dry  atmosphere, 
with  little  or  no  wind,  especially  after  heavy  rains,  increases  it. 

It  has  been  found  by  experience  that  certain  plants,  such  as 
the  sunflower  (Helianthus  Annus),  the  calamus  (Acorus  Cala- 
mus), and  the  eucalyptus,  have  the  power  of  absorbing  the 
miasm,  and  have  been  used  with  much  success  in  malarious 
districts. 

From  time  immemorial  malarial  fevers  have  been  observed  to 
show  a  tendency  to  ameliorate  or  terminate  on  certain  days, 
which  have  been  for  this  reason  denominated  "critical."  This 
tendency  has  been  variously  explained,  but  the  explanations 
are,  for  the  most  part,  more  fanciful  than  philosophical.  Clin- 
ical experience,  however,  endorses  the  statement  that  the  fever 


630  THE  DISEASES  OF  CHILDREN. 

is  more  apt  to  terminate  on  certain  days  than  others.  The 
critical  days  areas  follows:  the  third,  fifth,  seventh,  ninth, 
eleventh,  fourteenth,  seventeenth,  twenty-first,  twenty-seventh 
and  thirty-first.  The  non-critical  are  the  intermediate  days ; 
but  the  fourth  and  sixth  are  considered  secondarily  critical. 
Cases  that  pass  the  seventh  day  are  apt  to  run  on  to  the 
eleventh ;  and  those  which  pass  the  fourteenth  are  apt  to  go  to 
the  twenty-first. 

Symptotns  and  Course. — The  clinical  history  of  a  case  of  in- 
termittent fever,  which  is  the  commonest  form  of  malarial  poi- 
soning, is  about  as  follows  :  The  prodromal  or  incubative  stage, 
if  present,  is  of  variable  length  and  is  attended  by  indefinite 
symptoms,  or  none  at  all.  Some  patients  experience  a  sensa- 
tion of  languor,  accompanied  by  a  tired  feeling,  with  frontal 
headache,  yawning,  stretching  and  general  malaise.  The  tongue 
is  somewhat  furred  ;  the  appetite  is  impaired  or  lost  ;  there  is 
a  metallic  taste  in  the  mouth,  the  breath  is  foul  and  the  skin 
takes  on  a  dirty-yellow  or  icteric  hue  ;  the  urine  is  scanty  and 
high-colored  ;  the  fecal  discharges  are  dark-colored  and  offen- 
sive. After  these  symptoms,  or  some  of  them,  have  continued 
for  a  variable  period,  they  eventuate  in  a  distinct  rigor  usually, 
which  is  the  commencement  of  that  series  of  phenomena  which 
characterize  the  paroxysmal  stage.  This  stage  is,  in  a  typical 
case,  marked  by  three  distinct  divisions :  first,  the  chill ;  second, 
the  fever  ;  third,  the  sweat. 

When  the  attack  presents  itself  every  day,  it  is  called  quotid- 
ian ;  every  other  day,  tertian ;  every  fourth  day,  quartan.  In 
double  quotidian,  there  are  two  chills  daily — one  in  the  morning 
and  one  in  the  evening.  In  double  quartan,  there  is  an  attack 
on  two  successive  days  and  one  day  without  an  attack ;  in 
double  tertian  one  chill  daily,  but  the  time  of  chill  alternates 
every  other  day.  In  children  the  quotidian  form  is  most  com- 
mon. Bohn  gives  the  relative  frequency  of  the  three  forms  as 
3:2:1,  although  this  varies  according  to  the  nature  of  the  epi- 
demic. 

As  a  rule,  to  which  there  are  apt  to  be  exceptions,  the  attack 
comes  on  between  ten  o'clock  in  the  morning  and  one  in  the 
afternoon.  There  are  two  forms  of  intermittent  fever  and  of 
very  different  gravity — the  pernicious  and  the  mild  form. 

The  first  or  pernicious  form,  is  not  uncommon  in  infancy  and 
childhood,  and  is  generally  ushered  in  with  a  convulsion  instead 
of  a  chill.  The  child  may  be  attacked  in  the  midst  of  perfect 
health,  or  may  be  for  a  short  time  restless  and  feverish.  Yawn- 
ing and  stretching  are  among  the  more  noticeable  prodromata. 
There  is  sometimes  vomiting  or  one  or  more  loose  evacuations 
just  preceding  an   attack.     Quite  as  often,  in  this  pernicious 


IN  TERM  I T  TEN  T  FE  VER.  631 

variety,  the  first  evidence  of  illness,  is  a  turning  of  the  face  a 
pale  or  bluish-pale  color,  and  very  shortly  the  child  has  a  con- 
vulsion or  falls  into  a  comatose  state,  from  which  it  never  ral- 
lies, remaining  in  this  condition  for  one,  two  or  more  days  and 
finally  dying  from  asthenia,  edema  of  the  brain,  or  some  other 
complication.  If  the  first  attack  does  not  prove  fatal,  the  con- 
vulsions gradually  diminish  in  intensity  and  number,  the  ex- 
tremities grow  warmer,  the  bluish  color  and  the  pallor  disappear, 
and  the  temperature  begins  to  fall.  After  a  time  the  child 
resumes  consciousness,-'and  soon  is  apparently  quite  well  again. 
But  the  next  day  or  the  day  after  the  attack  is  renewed,  and 
this  second  paroxysm  may  end  fatally  The  temperature,  if 
taken  during  a  paroxysm  and  in  the  rectum,  is  very  high  (104° 
or  even  108°  Fahr.).  The  pupils  are  contracted,  or  one  may  be 
contracted  and  the  other  dilated.  The  child  may  be  comatose 
from  the  beginning,  or  the  convulsions  may  precede  the  coma. 

When  the  attack  comes  on  thus  suddenly,  in  a  previously 
healthy  subject,  the  diagnosis  is  sometimes  very  difficult  to 
make.  The  resemblance  to  cerebro-spinal  fever  is  exceedingly 
close.  The  character  of  the  locality  and  the  known  presence  of 
the  miasm  may  be  the  only  clue  to  the  real  nature  of  the  seiz- 
ure. 

It  is  very  rare  indeed  for  these  pernicious  cases  to  terminate 
otherwise  than  fatally.  In  the  benign  form  of  intermittent 
fever,  the  attendant  phenomena  vary  with  age.  In  young  in- 
fants we  rarely  have  a  complete  attack — that  is,  a  complete 
sequence  of  stages.  It  is  asserted  by  some,  that  infants  do 
have  the  chill,  fever  and  sweat,  the  same  as  adults;  but  this  is 
surely  exceptional.  More  often  one  of  the  links  is  missing,  and 
usually  this  is  the  chill,  a  convulsion  frequently  taking  its 
place,  the  other  stages,  fever  and  sweat,  following  in  their 
regular  order.  Infants  who  do  not  have  a  distinct  rigor,  may 
have  symptoms  which  very  nearly  approach  a  chill,  viz.:  cold- 
ness of  the  nose  and  extremities ;  blueness  of  the  lips ;  dark 
circles  about  the  eyes,  and  a  look  of  great  exhaustion.  If  the 
child  has  just  eaten,  there  is  apt  to  be  vomiting,  or  at  least 
nausea.  If  convulsions  take  the  place  of  the  chill,  as  just  des- 
cribed, they  are  not  likely  to  be  much  prolonged — rarely  last- 
ing more  than  a  few  hours — when  the  next  stage,  that  of  fever, 
ensues.  During  the  chill  or  convulsions,  the  temperature 
rapidly  rises  to  103°  or  higher,  and  remains  there  until  the 
paroxysm  is  over,  when  it  gradually  diminishes,  until,  after  the 
lapse  of  several  hours,  it  reaches  a  normal  or  subnormal  degree. 
The  sweat  that  follows  is  profuse  and  exhausting,  yet,  strange 
to  say,  no  sooner  is  it  over  than  the  appetite  returns,  the  face 
brightens  up  and  the  child  seems  quite  well  again.     After  a 


632  THE  DISEASES  OF  CHILDREN. 

succession  of  attacks,  however,  the  cachexia  begins  to  manifest 
itself ;  the  complexion  loses  its  natural  color,  and  is  pale  or 
jaundiced.  The  patients  now  become  listless  and  lose  their 
appetites.  The  spleen  becomes  enlarged,  either  temporarily 
or  permanently,  and  may  usually  be  felt  by  careful  palpation 
through  the  abdominal  walls.  With  older  children,  who  are 
able  to  describe  their  sensations,  the  symptoms  do  not  differ 
essentially  from  those  seen  in  adults,  especially  in  typical  cases. 
But  children  are  more  prone  than  adults  to  suffer  from  the 
cachexia,  and  then  we  have  all  manner  of  symptoms  and  com- 
binations of  symptoms,  which  are  oftentimes  exceedingly 
puzzling. 

It  would  be  impossible  to  give  even  a  rdsume  of  the  various 
phases  which  the  malarial  cachexia  may  assume  under  varying 
circumstances.  In  some  cases  the  chill  is  absent,  and  the  other 
stages  are  manifested  in  a  partial  or  fragmentary  form.  In 
these  cases  there  is  more  or  less  fever,  followed  by  a  sweat,  and 
the  periodicity  may  be  regular  or  irregular.  The  popular  name 
for  such  an  attack  is  "  dumb  ague." 

Oftentimes  the  chill  and  the  fever  are  replaced  by  an  intense 
neuralgia,  appearing  daily  about  the  same  hour,  or  perhaps 
every  other  day.  In  young  children  masked  intermit  tents  of 
this  kind,  are  apt  to  take  the  form  of  diarrhea,  dysentery  or 
dyspepsia.  But  there  is  no  disturbance  of  function  nor  disease 
of  any  organ  or  tissue,  but  may  be  influenced  by  the  malarial 
poison,  and  take  on  a  periodicity  unknown  to  similar  com- 
plaints outside  of  malarious  localities,  or  at  least  unknown  ta 
those  who  have  not  been  exposed  to  miasmatic  influences. 

Diagnosis. — It  is  only  in  masked  cases,  which  have  the 
cachexia,  but  not  the  regular  paroxysms,  that  there  can  be  any 
difficulty  about  the  diagnosis.  In  such  cases  there  is  pretty 
sure  to  be  more  or  less  enlargement  of  the  spleen  ;  and  the  his- 
tory of  the  case,  with  a  knowledge  of  the  existence  of  malaria 
in  the  neighborhood  where  the  patient  has  recently  sojourned, 
will,  by  the  help  of  the  rule  of  exclusion,  aid  in  reaching  a  satis- 
factory conclusion.  In  a  typical  case  of  intermittent,  the  diag- 
nosis is  easy.  There  is  a  regular  succession  of  phenomena  and 
a  repetition  of  these  phenomena.  In  pyemia,  the  accession  of 
the  fever  observes  no  regularity  and  there  is  no  complete  inter- 
mission. The  temperature  in  pyemia  never  approaches  the 
normal,  while  in  intermittent  fever  there  is  a  period  of  complete 
defervescence.  Remittent  fever  usually  has  but  one  chill,, 
while  in  intermittent  fever  a  chill  inaugurates  each  paroxysm. 

In  the  hectic  fever  which  accompanies  pulmonary  phthisis, 
the  paroxysms  occur  more  often  in  the  afternoon  than  the  fore- 
noon, and  the   intermissions  are    incomplete.     The   question. 


INTERMITTENT  FE  VER.  63E 

however,  is  as  a  rule  easily  settled  by  physical  exploration,  for 
in  tuberculous  disease  the  physical  signs  are  seldom  wanting. 

Prognosis. — In  the  pernicious  variety  of  intermittent  fever, 
or,  rather,  the  pernicious  form  of  malarial  poisoning — for  there 
is,  in  such  cases,  seldom  more  than  a  single  paroxysm — the 
prognosis  is  very  grave.  Fortunately,  congestive  chills — for 
such  in  reality  they  are — are  not  common,  except  in  certain 
restricted  regions  of  the  extreme  south.  In  more  northerly 
latitudes  the  fever  is  of  the  benign  form  and  seldom  results 
fatally.  The  cachexia  which  is  left  by  the  poison,  and  which  is 
very  hard  to  eradicate  from  the  system,  is  its  worst  feature. 
It  not  only  remains  as  a  constant  menace  to  the  health  for  an 
indefinite  period,  giving  to  each  intercurrent  disease  a  more 
serious  aspect,  but  it  lays  the  foundation  for  an  innumerable 
train  of  chronic  ills  that  make  life  a  burden,  if  it  does  not 
materially  abbreviate  it.  Children,  however,  are  less  liable  to 
be  permanently  affected  by  this  cachexia  than  are  adults. 
They  outgrow  it  as  they  mature,  especially  if  a  change  of  resi- 
dence is  effected  to  a  non-malarious  locality. 

Treatment. — The  object  of  treatment  in  intermittent  fever  is 
two-fold :  first,  to  arrest  the  paroxysms,  and  secondly,  to  over- 
come the  cachexia.  The  first  is  much  more  easily  achieved 
than  the  second.  There  is  usually  not  much  trouble  in  stop- 
ping the  chills.  The  greatest  trouble  is  in  eliminating  the 
poison  from  the  system  or  rendering  it  inert.  More  cases  are 
suppressed  than  cured.  For  the  accomplishment  of  the  first 
object — the  arrest  of  the  paroxysms — there  are  but  two  drugs 
known  that  are  worth  mentioning,  viz.,  quinin  and  arsenic.  It 
was  from  a  study  of  the  action  of  Peruvian  bark,  and  the  aggra- 
vation which  he  witnessed  from  the  use  of  it  in  toxic  doses, 
that  the  master  mind  of  Hahnemann  first  conceived  the  law  of 
similars,  which  is  the  foundation  stone  of  our  school  of  practice. 
Quinin  will  produce  in  a  healthy  organism  all  of  the  essential 
phenomena  of  intermittent  fever — the  chill,  fever,  sweat.  It  is 
therefore  truly  homeopathic  to  this  portion  of  the  disease,  and 
if  given  in  the  beginning  of  an  attack,  or  during  an  intermission, 
it  will  ordinarily  prevent  or  arrest  the  succeeding  attack.  But 
it  will  not  always  do  it,  probably  because  it  is  not  always  given 
in  appropriate  doses.  And  it  will  not  remove  the  underlying 
cachexia.  For  this  latter  purpose,  a  close  study  of  the  materia 
medica  will  have  to  be  made,  and  the  curative  remedy  will  have 
to  be  selected  with  due  regard  to  the  individual  case  and  the 
totality  of  the  symptoms.  In  ordinary  cases  the  dose  of  quinine 
— graduated  by  the  age  of  the  child — will  be  from  one  to  three 
grains,  repeated  every  one,  two  or  three  hours,  according  to  the 
severity  of  the  attack.     The  most  effectual  time  to  administer 


534  THE  DISEASES  OF  CHILDREN. 

it  is  during  an  intermission,  and  to  get  enough  of  the  drug  into 
the  system  to  accomplish  the  desired  object,  it  should  be  given 
frequently  or  freely  ;  its  use  should  then  be  suspended  until 
the  next  intermission.  The  great  objection  to  quinin  as  a 
remedy  for  children  is  its  taste.  It  is  intensely  bitter,  and 
there  is  no  known  means  of  disguising  it  so  as  to  render  it  pal- 
atable. It  cannot  be  given  per  rectum  on  account  of  the  irri- 
tability which  it  excites.  It  is  said  to  act  well  as  a  tonic  when 
given  endermically,  i.  e.,  by  inunction  ;  but  the  skin  will  not 
absorb  enough  of  it  to  act  as  an  anti-periodic.  The  use  of  licorice 
or  other  menstrua  only  increases  the  bulk  of  the  dose  without 
materially  modifying  its  taste.  The  best  way  is  to  give  it  in 
solution  or  wafer,  and  follow  its  administration  with  some  fruit 
jelly  or  orange  juice,  to  get  rid  of  the  taste  left  behind. 

In  cases  where  the  stomach  will  not  tolerate  quinin,  we  can 
give  the  next  best  drug,  which  fortunately  is  tasteless,  or  nearly 
so.  We  refer  to  arsenic,  or  arsenicum,  as  we  prefer  to  call  it. 
In  irregular  cases,  or  those  which  differ  from  the  typical  form, 
in  having  the  chill  omitted  or  a  prolongation  of  the  other  stages, 
this  remedy  is  even  better  than  quinin. 

In  grave  cases,  where  quinin  is  inadmissible,  and  we  want  to 
check  the  paroxysm,  we  may  give  an  infant  under  six  months  a 
drop  of  Fowler's  solution,  and  increase  the  dose  to  two  or  even 
three  drops  with  older  children.  When  we  give  it  more  for  the  ca- 
chexia than  to  arrest  theparoxysms,  our  third  or  fourth  decimal 
trituration  will  be  amply  strong  enough  for  all  practical  pur- 
poses. An  admirable  preparation,  and  one  which  has  succeeded 
well  in  our  hands,  is  the  arsetiiate  of  quinia  {chm.  ars.).  It  is 
very  successful  in  masked  intermittents,  and  in  mixed  types  of 
simple  intermittent.     We  give  it  in  2x  or  3X  trituration. 

It  would  be  impossible  to  give  the  symptomatic  indications 
for  quinin,  for,  as  Dr.  E.  W.  Jones  wisely  says:  "  The  most  di- 
verse symptomatic  series  have  been  cured  by  it,  and  in  doses 
varying  from  the  truly  infinitesimal  to  twenty-grain  doses  of 
the  crude  drug.  A  remedy  which  is  so  universally  used  as 
quinin  can  scarcely  have  defined  indications  that  will  cover  all 
of  its  apparent  range."  It  does  not  seem  to  have  any  effect 
over  the  cachexia,  unless  it  be  to  aggravate  it,  and  never  should 
be  given  except  for  its  well-known  anti-periodic  power.  To 
overcome  the  cachexia  there  are  other  drugs  which  will  follow 
either  quinin  or  arsenicum,  and  may  be  given  with  good  pros- 
pects of  success. 

Arsenicum  alb. — Increased  secretion  of  acrid,  corroding  tears; 
face  pale,  waxy  and  expressive  of  suffering  ;  tongue  furred, 
with  red  streak  in  middle  and  red  tip  ;  excessive  thirst  ;  drinks 
often,  but  little  at  a  time  ;  drinking  cold  water  does  not  satisfy 


INTERMITTENT  FEVER.  635 

and  causes  nausea  ;  no  appetite,  with  nausea  when  time  for  fever 
to  return  ;  violent  pain  in  region  of  stomach  ;  stools  dark,  bloody, 
watery,  offensive  and  very  acrid,  excoriating  the  anus  and  but- 
tocks ;  pulse  small,  quick,  weak,  irregular  and  scarcely  percep- 
tible ;  excessive  weakness  and  prostration  ;  intensely  restless 
and  nervous  ;  sleep  disturbed,  broken  with  moanings  as  if  in  pain ; 
cold,  clammy,  offensive  perspiration  with  great  thirst ;  yawnings 
and  stretchings  before  chills  ;  paroxysms  irregularly  developed ; 
chills  may  predominate  and  fever  be  entirely  absent,  or  heat 
and  fever  and  profuse  sweat,  but  no  chills ;  all  symptoms  worse 
at  night  and  from  cold,  better  from  warmth  in  general.  Espe- 
cially useful  in  tertian  types. 

Belladonna. — Quarrelsome,  irritable  temper ;  eyes  red,  hot 
and  sparkling,  pupils  dilated,  intolerance  of  light,  profuse  bland 
lachrymation  ;  face  intensely  hot  and  red  ;  throbbing  and  bound- 
ing of  carotids ;  tongue  dry,  red,  hot,  with  white  streak  in  cen- 
ter ;  intolerable  thirst  for  cold  water ;  sharp,  painful  stitches, 
coming  and  going  like  a  flash  ;  stools  slimy,  bloody,  with  hard 
lumps  mixed  with  green  mucus ;  pulse  full,  rapid,  hard  and 
bounding ;  spasms,  convulsions ;  restless,  throws  body  back- 
ward and  forward  ;  skin  hot  all  over,  with  perspiration  beginning 
at  the  feet  and  extending  upward ;  starting  in  sleep,  with  jerk- 
ings  of  the  head  and  feet ;  sweat  stains  the  bed  linen.  Espe- 
cially useful  in  the  quotidian  and  congestive  types  of  the  inter- 
mittent. 

Bryonia. — Very  irritable,  sullen  and  frightened  ;  violent  throb- 
bing headache,  with  pains  down  the  neck,  worse  mornings  ; 
face  hot  and  with  circumscribed  red  spot  over  malar  bones ; 
excessive  thirst  for  immense  quantities  of  cold  water  ;  tongue 
coated  with  heavy  white  fur,  tip  moist  and  red ;  nausea  and 
vomiting,  relieved  by  large  quantities  of  cold  water  ;  pressure  in 
stomach  after  eating  causes  great  anxiety  and  distress ;  diar- 
rheic  stools  of  offensive,  pasty,  acrid  matter,  or  constipation, 
with  hard,  dry  stools  passed  with  difficulty  ;  dry,  short,  violent 
cough ;  exhausted  and  weak ;  stitches  in  joints  and  various 
parts  of  body,  worse  on  slightest  motion  and  touch  ;  chill  begins 
at  tips  of  fingers  and  toes,  thence  spreading  over  body  ;  chills 
are  creeping  rather  than  shaking  ;  sweats  on  side  laid  on  ;  per- 
spiration sour,  oily,  profuse,  offensive,  and  easily  excited. 

China  ars. — Irritable,  wants  to  be  let  alone  ;  face  pale  and  lips 
blue  ;  tongue  coated  brown  ;  excessive  thirst,  which  relieves  the 
nausea  and  vomiting  ;  pulse  small,  weak,  irregular  and  very 
high  (200) ;  extremities  cold,  like  ice  ;  chill  in  morning  at  vari- 
able hour,  followed  towards  night  by  intense  fever ;  prostra- 
tion ;  spasms.  Useful  in  the  masked  and  poorly  developed 
intermittents. 


636  THE  DISEASES  OF  CHILDREN. 

China  siilph. — Mind  first  bright  and  excited,  later,  moody, 
dull  and  irritable  ;  ringing  and  roaring  in  ears  ;  profuse  epistaxis 
in  morning ;  face  swollen,  dirty  and  with  sickly  expression ; 
tongue  swollen,  flabby  and  coated  with  thick  yellow  fur ;  great 
thirst,  but  no  appetite  ;  vomiting  of  sour,  intensely  bitter  bile  ; 
painful  enlargement  of  the  spleen  ;  dysenteric  stools,  stools  soft, 
dark,  frothy  and  accompanied  by  large  quantities  of  offensive 
flatus ;  urine  high-colored  and  deposits  heavy  brick-dust  sedi- 
ment ;  all  senses  excessively  acute ;  very  weak  and  prostrated 
after  stools ;  chills  occur  at  same  hour  with  clock-like  regular- 
ity; stage  of  fever  gradually  passes  into  perspiration,  with  in- 
tense thirst,  which  is  greatly  relieved  by  large  quantities  of 
water, 

Cina. — Ill-humored,  cannot  be  quieted  ;  constantly  boring  and 
picking  at  the  nose  with  the  fingers ;  tongue  clean,  but  very 
painful ;  excessive  appetite  all  the  time,  is  hungry  after  eating; 
intense  nausea  and  retching,  vomiting  only  mucus  ;  thin,  watery, 
painless  diarrhea ;  face  is  pale,  lips  blue,  heat  and  redness  on 
cheeks ;  perspiration  on  forehead,  face  and  hands ;  feels  chilly, 
even  when  near  a  hot  stove. 

Eupatorium  p€rf. — Intense  aching  in  all  the  bones  of  the 
body ;  intense  thirst  for  cold  water,  which  causes  vomiting; 
vomiting  of  dark-green,  very  bitter  mucus,  which  causes  great 
weakness  ;  cannot  bear  weight  of  clothes  over  hepatic  region  ; 
morning  diarrhea,  with  burning  in  anus  and  rectum ;  back  and 
limbs  feel  as  if  beaten  and  are  very  painful ;  thirst  before  chill 
and  continuing  during  the  chill  and  fever ;  vomiting  of  bile  after 
chill ;  shivers  all  out  of  proportion  to  the  degree  of  chilliness ; 
chill  in  morning  one  day  and  afternoon  the  next  day;  sweating 
stage  may  be  very  profuse  or  entirely  absent. 

Gelsemium. — Great  mental  apathy  or  is  very  nervous;  face 
flushed  and  hot ;  tongue  coated  yellowish  white ;  pulse  rapid 
with  increased  arterial  tension ;  relaxation  and  prostration  of 
entire  muscular  system  ;  chill  begins  in  hands  and  feet  and  ex- 
tends to  the  back;  fever  very  high,  but  no  thirst ;  the  intermis- 
sions may  be  very  marked  or  entirely  absent ;  chill  usually  be- 
gins in  evening ;  very  restless  and  sleepless. 

Ipecac. — Very  peevish,  irritable  and  cries  constantly;  face  is 
very  cold  and  sunken  ;  intense,  painful  and  long-lasting  nausea 
and  retching  continues  through  all  the  stages ;  saliva  increased 
and  runs  from  the  mouth  ;  great  weakness,  with  jerking  and 
twitching  of  the  arms  and  legs ;  intermissions  so  poorly  marked 
as  to  be  unnoticeable ;  body  feels  cold,  yet  there  is  high  fever ; 
profuse,  sour-smelling  perspiration  which  stains  linen  yellow. 
Useful  after  abuse  of  quinin. 

Natrutn  mur. — Intense  congestion  of  the  head  and  face,  face 


IN  TERM  I T  TEN  T  FEVER.  637 

very  shiny ;  lips  dry,  cracked  and  ulcerated ;  very  bitter,  salty 
taste  in  mouth  mornings ;  tongue  coated  white,  with  sensa- 
tion as  if  something  was  on  it ;  violent,  unquenchable  thirst  for 
immense  quantities  of  water  frequently  renewed ;  vomiting  of 
the  water  soon  after  it  is  drunk;  intense  burning  pain  in  ure- 
thra, so  that  child  screams  when  urinating  ;  urine  very  pale,  and 
copious,  uric-acid  sediment ;  rapid,  weak,  intermittent  pulse ; 
chill  in  mornings,  begins  in  hands  and  feet,  nails  very  blue  ; 
chilly  stage  passes  directly  to  the  fever ;  the  chill  is  long-lasting, 
body  feels  very  cold,  but  internal  heat. 

Nux  vomica. — Irritable  and  peevish  ;  dizziness  with  pain  in 
head ;  tongue  thickly  coated  white,  with  offensive  breath  ;  vom- 
iting of  very  bitter,  sour  mucus ;  intense  thirst,  which  is  satis- 
fied by  milk;  diarrhea  in  morning,  with  dark-colored  stools,  or 
constipated  and  stools  light  and  very  hard  ;  severe,  long-lasting 
chills,  preceded  and  followed  by  heat ;  chills  are  accompanied 
by  shakings  of  the  whole  body,  with  pale  or  blue  nails ;  chills 
so  severe  as  not  to  be  relieved  by  heat  and  great  quantities  of 
clothing,  shivers  on  slightest  motion  ;  heat,  without  sweat,  and 
cannot  uncover  without  shivering ;  sour,  offensive,  profuse 
perspiration  after  fever. 

Pulsatilla. — Fretful,  anxious,  and  easily  frightened  ;  dizziness 
and  pain  in  the  head,  with  nausea,  which  is  relieved  by  lying 
down ;  tongue  dry,  white  and  covered  with  a  thick,  tenacious 
mucus;  disgust  for  meat  and  fatty  foods;  painful  diarrhea, 
stools  mixed  with  green  mucus,  or  only  mucus;  involuntary 
passage  of  copious,  pale  urine ;  palpitation  in  pulse  felt  in  ab- 
domen ;  yawns  and  is  very  sleepy  during  the  day,  wakeful  at 
night ;  chill  in  afternoon,  begins  over  abdomen  and  extends  to 
back ;  fever  is  intolerable,  begins  in  hands  ,  venous  congestions, 
no  thirst ;  profuse  sweat  on  one  side  only.  Especially  useful 
in  relapses  from  dietetic  errors. 


CHAPTER  IV. 

RHEUMATISM. 

Acute  rheumatism  is  not,  strictly  considered,  a  disease  of 
early  life.  It  does  not  belong  especially  to  any  age,  or  sex,  or 
nationality.  But  when  it  occurs  in  infancy  or  childhood,  it 
exhibits  certain  peculiarities  and  is  attended  with  certain  dan- 
gers, which  render  its  brief  consideration  here  imperative.  So 
often  does  it  afTect  the  heart  in  childhood,  causing  inflamma- 
tion of  its  valves,  that  endocarditis  and  rheumatism  are  almost 
synonymous  terms.  This  tendency  of  the  disease  to  molest 
the  sero-fibrous  tissues  is  so  universal  and  so  marked  that  any 
considerable  disturbance  of  the  heart's  action  always  creates  a 
suspicion  of  a  preceding  attack  of  rheumatism,  and  in  the  large 
majority  of  cases,  if  the  family  history  be  traced  back,  the  sus- 
picion will  prove  to  have  been  well  founded.  Nor  is  this  due 
to  the  preponderance  of  rheumatism  over  other  constitutional 
or  general  maladies  in  parents,  but  rather  to  the  fact  that  the 
rheumatic  diathesis  is  one  which  is  readily  transmissible,  and 
children  of  rheumatic  parents  are  very  prone  to  have  endocar- 
dial trouble,  notwithstanding  the  fact  that  the  rheumatism  from 
which  they  have  personally  suffered  may  have  been  so  slight 
and  transient  as  to  have  been  entirely  overlooked.  Children 
are  frequently  brought  to  the  physician's  office  or  to  the  out- 
door clinics,  with  a  well-developed  mitral  lesion,  whose  parents 
will  insist  that  they  have  never  had  an  attack  of  rheumatism 
or  anything  like  it,  unless  "growing  pains"  might  be  called 
such.  Close  questioning,  however,  will  elicit  the  fact  that  these 
same  children  have  more  or  less  frequently  complained  of  va- 
grant pains  here  and  there,  stiff  neck,  lameness,  etc.,  which  were 
so  trifling  and  of  such  short  duration  that  little  attention  was 
paid  to  them. 

Inspection  of  the  body  will  reveal  the  presence  here  and 
there  of  subcutaneous  nodules — small  bullae — about  the  vari- 
ous joints. 

These  inconspicuous  masses — frequently  more  palpable  than 
visible — are  found  about  the  elbow,  the  melleoli,  the  margins  of 
the  patella  and  elsewhere ;  they  may  be  solitary  or  in  crops,  are 
painless,  and  appear  and  disappear  in  the  course  of  a  few  weeks, 
although  they  sometimes  remain  for  months.  They  are  not 
(638) 


RHE  UMA  TISM.  639 

pathognomonic  of  rheumatism,  but  are  so  commonly  present 
in  the  rheumatic  constitution,  that  they  possess  considerable 
diagnostic  importance  in  doubtful  cases.  Drs.  Barlow  and 
Warner  have  shown  that  they  are  almost  invariably  associated 
with  disease  of  the  heart,  and  usually  in  connection  with  some 
progressive  form  of  disease.  Prof.  E.  M.  Hale  has  so  admira- 
bly covered  the  cases  of  heart  affection  from  rheumatic  and 
other  causes,  that  nothing  more  need  be  said  here  upon  that 
subject.  It  is  only  mentioned  now  to  call  the  reader's  atten- 
tion to  the  subject  and  direct  him  where  to  find  it  fully 
discussed.     See  page  383  et  seq. 

Of  rheumatism,  in  general,  as  manifested  in  early  life,  it  may 
be  said  that  children  suffer,  as  a  rule,  less  intensely  and  for  a 
shorter  period  than  do  adults.  The  pain  is  generally  less 
severe,  and  the  edema  about  an  affected  joint  is  usually  less. 
Indeed,  the  great  majority  of  children  affected  with  rheumatism 
make  so  little  complaint  about  acute  symptoms,  that  there  is 
far  more  danger  of  overlooking  the  affection  than  of  mistaking 
it  for  something  else. 

The  copious  acid  sweats,  which  are  so  common  in  adults 
affected  with  rheumatism,  are  almost  unknown  with  children.  It 
must  not  be  inferred  from  what  has  been  said  that  these  trifling 
attacks  are  to  be  ignored  or  treated  lightly,  for  however  insig- 
nificant the  attack  may  be  it  is  liable  to  produce  serious  and 
permanent  heart  damage.  This  is  the  more  true  the  younger 
the  patient.  The  so-called  "  growing  pains ;"  a  slight  swelling 
of  a  single  joint ;  a  transient  pain  in  the  intercostals ;  pleurisy, 
pericarditis,  pleurodynia,  are  all  indicative  of  the  rheumatic 
diathesis. 

It  is  plain  from  this  description  that  the  symptoms  of  acute 
rheumatism  in  early  life  are  often  indefinite  in  character,  but 
none  the  less  serious  in  import.  But  children — even  young 
infants — do  have  exceptionally  the  same  form  of  rheumatism 
as  adults,  attended  with  a  moderate  amount  of  fever,  with  a 
joint  or  joints  which  are  painful,  hot,  red  and  swollen.  The 
swelling  is  due  to  inflammatory  edema  of  the  tissues  in  and  sur- 
rounding the  joint.  This  effused  fluid  is  for  the  most  part 
serum,  and  resembles  the  effusion  of  pleurisy.  Like  the  pleu- 
ritic exudation,  it  may  contain  a  few  globules  of  pus,  and  in  rare 
and  exceptional  cases  the  amount  of  pus  may  be  so  great  as  to 
constitute  a  true  arthritic  abscess.  In  most  cases,  however, 
the  exudation  is  mainly  serous,  and  hence  is  readily  absorbed. 
The  intensity  of  the  pain  is  only  felt  when  the  affected  limb  is 
moved  or  the  joint  pressed  upon.  Sometimes  rheumatism 
affects  but  a  single  joint  of  one  of  the  extremities,  but  occa- 
sionally it  invades  the  trunk  and  involves  the  articulations  of 


640  THE  DISEASES  OF  CHILDREN. 

the  vertebra,  the  symphysis  pubis,  or  the  costo-chondrals. 
There  is  great  tendency  in  rheumatism  to  wander  about  so  that, 
as  the  disease  abates  in  the  articulations  first  affected,  it  re- 
appears in  others  either  near  or  remote.  Fortunately  for  the 
patient,  it  is  rare  that  more  than  two  or  three  joints  are  in  a 
state  of  active  inflammation  at  the  same  time. 

In  cases  where  the  rheumatism  is  secondary  to  some  other 
complaint,  such  as  the  eruptive  fevers,  it  commonly  affects  only 
a  few  joints,  often  but  a  single  one,  and  this  is  attended  by  but 
slight  swelling  and  redness.  Fluctuations  are  common,  and 
just  as  the  patient  seems  about  to  recover,  the  pain  and  asso- 
ciate phenomena  jump  to  some  hitherto  unaffected  joint  or 
tissue,  and  thus  the  affection  is  prolonged.  More  or  less  stiff- 
ness is  commonly  left  in  the  joints  which  have  been  involved, 
and  this  may  remain  for  some  considerable  time,  but  is  seldom 
permanent,  unless  the  disease  itself  becomes  chronic. 

Treatment. — The  treatment  of  rheumatism  may  be  properly 
divided  into,  first,  prophylactic ;  second,  palliative  ;  and  third, 
curative.  The  youthful  subjects  of  rheumatism  are  usually 
anemic  and  sensitive  to  atmospheric  changes.  This  is  more 
especially  true  of  those  who  inherit  the  rheumatic  tendency. 
Such  children  require  to  be  well  clad  with  woolen  garments, 
and  their  feet  should  be  well  protected  against  dampness. 
Their  diet  should  be  carefully  regulated  and  restricted  in  the 
matter  of  sweets  and  all  other  fermentable  foods.  The  diges- 
tive organs  of  these  children  are  easily  upset,  and  indigestion 
or  anything  which  reduces  the  system  below  par  is  deleterious. 
The  rheumatic  child  easily  takes  cold,  and  is  exhausted  with 
equal  ease.  Exercise  should  therefore  be  moderate.  Both 
study  and  recreation  should  be  kept  within  judicious  and  safe 
limits.  Everything,  in  a  word,  should  be  done  to  keep  the 
child  well  in  a  general  way.  It  goes  without  saying  that  a  dry 
and  equable  climate  is  better  for  rheumatic  subjects  than  a 
damp  and  changeable  one. 

Palliative  treatment  consists  in  swathing  the  affected  parts 
with  wool  or  cotton,  which  may  be  kept  warm  by  being  fre- 
quently reapplied.  Hot  fomentations  with  witch  hazel  and 
water — half  and  half — are  usually  very  grateful.  All  repellant 
applications,  as  cold  or  irritants,  are  dangerous,  since  they  in- 
vite complications.  Absolute  rest  is  every  way  essential.  The 
diet  should  be  sustaining,  but  at  the  same  time  bland  and  un- 
stimulating.  The  bowels  should  be  kept  open  by  the  use  of 
fruits,  etc.,  and  if  necessary,  by  the  additional  use  of  supposi- 
tories or  enemata. 

Curative  treatment. — Rheumatism  is  universally  conceded  to 
be  caused  by  an  excessive  amount  of  acid  in  the  blood,  and 


RHEUMATISM.  641 

therefore  the  exhibition  of  alkalies  seems  to  be  founded  on 
reason  and  sense.  The  alkaline  treatment  is  not  only  theoret- 
ically correct,  but  clinical  experience  endorses  the  theory.  The 
use  of  acetate  of  potash  and  bicarbonate  of  soda  for  this  purpose 
has  given  place  to  the  salicylate  of  soda  treatment,  which  is 
undoubtedly  preferable  as  being  more  speedily  efficient.  By 
some  the  salicylate  of  lithia  is  preferred.  Either  drug  may  be 
given  to  a  child  of  from  three  to  five  years,  in  doses  of  two  and 
one-half  grains  every  three  hours,  for  three  or  four  days,  after 
which  it  need  not  be  repeated  oftener  than  three  times  a  day. 
It  may  be  given  in  syrup  or  any  other  available  medium.  To 
children  past  six  years  of  age  five  grains  may  be  given  at  a  dose 
without  a  particle  of  danger.  While  salicylic  acid  combined 
with  soda  or  lithia  salts  is  being  given  for  its  chemical  effects, 
the  homeopathic  remedy  should  be  given  with  special  reference 
to  the  local  manifestations  of  the  disease.  The  selection  of 
the  drug  for  the  case  in  hand  will  depend  on  the  site  of  the 
inflammation,  the  time  of  greatest  aggravation  of  pain,  the 
general  condition  of  the  patient,  etc.,  etc. 

D.  C— 41 


CHAPTER  V. 


ADENITIS  ;  LYMPHADENITIS  (NON-SPECIFIC  INFLAMMATION  OF 
LYMPHATIC   GLANDS). 

The  tendency  of  glands  in  the  neck  and  elsewhere  to  take 
on  congestion  and  inflammation  in  certain  persons,  especially 
children,  who  either  have  inherited  or  acquired  the  scrofulous 
or  strumous  taint,  is  universally  recognized,  and  has  been  men- 
tioned by  nearly  all  medical  writers  since  the  days  of  Hippoc- 
rates. Sometimes  this  tendency  is  the  only  clue  we  have  to 
the  scrofulous  diathesis ;  but  more  often  we  have,  sooner  or 
later,  the  symptoms  described  in  the  last  section,  and  are  com- 
pelled to  recognize  the  glandular  swelling  as  part  of  a  consti- 
tutional dyscrasia,  whose  depraved  influence  and  tendency  are 
as  widespread  as  the  bounds  of  the  organism.  But  there  are 
other  cases  occurring  every  now  and  again,  in  the  practice  of 
every  physician  of  large  experience,  in  which  there  is  swelling 
of  the  lymphatics  of  an  acute  or  chronic  character,  with  but 
little  tendency  to  suppuration,  and  in  children  who  show  no- 
where else,  and  in  no  other  way,  any  signs  of  tubercle,  scrofula 
or  struma.  They  neither  have  eczema  nor  catarrh,  nor  do  they 
have  the  general  appearance  of  those  who  are  the  manifest  sub- 
jects of  hereditary  taint.  All  that  can  be  said  of  them  is  that 
they  are  subject  to  glandular  swellings.  Why,  in  such  cases, 
the  cervical  glands  are  more  apt  to  be  implicated  than  others, 
has  been  a  matter  of  much  speculation.  That  they  are  so,  is 
beyond  question.  Treves  gives  the  following  table  of  the 
comparative  location  of  glandular  disease: 


Neck  alone 131 

Neck  and  axilla 12 

Groin  alone 6 


Axilla  alone 4 

Neck  and  groin i 

Neck,  groin  and  axilla i 


Some  authors  endeavor  to  account  for  this  great  preponder- 
ance of  cases  involving  the  neck  by  their  close  proximity  to  the 
tonsils,  which  are  the  largest  aggregation  of  adenoid  tissue  in 
the  body ;  and  this  theory  receives  much  plausibility  from  the 
fact  that  these  glands  are  so  frequently  enlarged  whenever  the 
tonsils  are  inflamed.  But  tonsilitis  is  not  the  only  proximal 
inflammation  or  irritation  that  may  give  rise  to  enlargement  of 
the  cervical  glands.  Eruptions  on  the  skin,  face  and  scalp, 
(642) 


9 

ADENITIS;  LYMPHADENITIS.  643 

coryza,  diseases  of  the  ear,  and  even  dentition  may  also  act  as 
indirect  causes.  Gastric  derangements,  also,  should  be  classed 
in  this  category,  but  beyond  doubt  "  taking  cold  "  is,  more  often 
than  anything  else,  the  immediate  or  exciting  cause.  That  the 
victims  of  adenitis  are  generally  delicate,  highly  organized  and 
sensitive  children,  is  true,  but  according  to  the  accepted  pathol- 
ogy of  that  disease,  mere  delicacy  of  organism  or  mere  depres- 
sion of  vital  powers  would  not  be  sufficient  to  produce  the  con- 
ditions known  as  scrofula.  Even  adults  in  ordinary  health,  and 
who  have  never  exhibited  symptoms  that  could  by  any  possi- 
bility create  a  suspicion  of  scrofulous  inheritance,  may  have 
temporary  engorgement  of  a  gland,  and  that  engorgement  may 
go  on  to  inflammation  and  suppuration. 

What  is  true  of  adults,  is  especially  true  of  children,  in  whom 
the  glandular  structures  are  proverbially  sensitive  to  peripheral 
irritation  or  to  reflex  influences  through  the  sympathetic  nervous 
system.  This  will  be  more  readily  understood  by  recalling  certain 
facts  from  anatomy  and  physiology  relative  to  the  lymphatic 
glands  and  their  function.  The  lymphatics  themselves  origi- 
nate  in  the  areolar  interspaces  and  are  everywhere  present. 
They  do  not  go  far  from  their  point  of  origin  before  they  meet 
other  lymphatics,  with  which  they  coalesce  and  expand  into  a 
lymphatic  gland,  with  efferent  ducts  or  lymph  channels  to  con- 
vey the  lymph  corpuscles  into  the  general  circulation.  Just 
how  these  lymph  corpuscles  originate  is  not  known,  but  every 
efferent  duct  is  filled  with  them,  and  anything  which  interferes 
with  their  progress  toward  the  general  blood-stream  is  produc- 
tive of  mischief.  In  children  the  waste  and  repair  of  tissue  is 
very  active,  and  the  function  of  the  lymphatics  is  to  pick  up 
waste  products,  which  are  mostly  albuminous,  and  conveying 
them  first  to  the  lymphatic  glands,  bring  them  ultimately  to  the 
general  circulatory  system.  All  effete  material  or  foreign  sub- 
stance  which  has  found  its  way  into  an  areolar  interspace,  is 
taken  up  by  the  open  mouths  of  the  lymphatics  and  passed 
through  the  glandular  mechanism.  Now,  bland  soluble  mat- 
ters, when  thus  taken  up  by  the  lymphatics,  pass  on  without 
hindrance  and  without  producing  congestion  or  irritation.  But 
it  is  different  when  the  matters  in  transit,  instead  of  being 
bland  and  soluble,  are  insoluble  or  irritating.  Then  the  gland 
is  liable  to  first  irritation  and  then  inflammation. 

When  the  surface  of  the  body  is  chilled,  as  from  cold,  all  of 
the  superficial  vessels  are  contracted  in  consequence,  the  lym- 
phatics as  well  as  others.  The  effect  of  this  contraction  is  to 
congest  the  glands  by  preventing  the  onward  flow  of  the 
lymph  corpuscles.  Hence  we  see  how  easily  from  cold  a  gland 
may  become  engorged,  congested,  and  then  inflamed. 


644  THE  DISEASES  OF  CHILDREN. 

In  the  neck  the  cervical  glands  are  large  as  well  as  numerous- 
being  made  up  of  innumerable  small  glands  conglomerated  to, 
gether.  All  glandular  structures  are  in  the  closest  relations  of 
sympathy,  and  so  we  see  how  an  inflammation  of  the  tonsils, 
to  use  these  organs  again  by  way  of  illustration,  may  extend  to 
the  adjacent  glands  of  the  neck. 

In  scrofulous  subjects,  the  processes  of  metabolism  are  im- 
perfectly performed,  the  elaborated  tissues  are  only  partially 
elaborated,  and  the  waste  products  are  only  partially  soluble. 
Hence  such  persons  have  constant  trouble  from  glandular  dis- 
ease. But  others,  also,  are  liable  to  glandular  engorgement 
from  cold  or  peripheral  irritation,  although  at  other  times  and 
under  other  circumstances  the  lymphatic  system  is  in  perfect 
working  order,  and  the  processes  of  metabolism  are  carried  on 
in  a  physiological  manner.  In  scrofulous  subjects,  glandular 
swellings  are  general  in  their  causation,  while  in  non-strumous 
subjects  these  causes  are  mostly  or  entirely  local.  Clinical  ex- 
perience teaches  that  when  inflammation  is  set  up  in  a  gland 
the  changes  effected  therein  are  manifested  first  in  the  deeper 
portions  of  the  glandular  structure,  beginning  in  the  medulla 
and  extending  thence  to  the  cortical  portions,  and  never  invad- 
ing its  capsule.  Sometimes,  when  the  gland  is  merely  con- 
gested or  engorged  and  not  inflamed,  the  obstructing  material 
only  undergoes  partial  absorption  and  remains  a  fibroid  callus. 
A  gland  is  then  said  to  be  indurated,  and  may  remain  in  this 
condition  indefinitely. 

In  other  cases,  the  gland  becomes  inflamed  and  pus  is 
formed ;  which  finds  a  superficial  outlet  or  burrows  into  the 
deep-seated  structures,  before  discharging  into  some  internal 
organ  or  tissue.  We  have  entered  into  this  somewhat  elaborate 
argument  to  prove  that  all  glandular  swellings  are  not  necessa- 
rily scrofulous  or  tubercular  in  their  nature  ;  that  certain  glands, 
especially  those  in  the  neck,  may  be  temporarily  engorged,  and 
this  engorgement  may  go  on  to  inflammation  and  suppuration, 
either  of  the  gland  itself  or  of  the  tissues  around  it,  without 
implying  any  perversity  of  constitution  or  any  morbidity  of 
histological  processes  or  products,  other  than  those  of  a  local 
and  generally  ephemeral  character. 

Symptoms. — There  is  one  point  of  difference  between  gland- 
ular infiltration  of  strumous  origin  and  that  non-specific  form 
which  we  are  now  considering.  The  latter  is  always  acute  and 
accompanied  with  acute  symptoms,  while  scrofulous  glands  are 
proverbial  for  the  chronic  and  indolent  character  of  their  ail- 
ments. The  more  marked  the  strumous  diathesis,  the  more 
true  is  this  observation. 

A  scrofulous  gland  may  show  no  symptoms  of  its  distress  in 


ADENITIS;  LTMPH ADENITIS.  645 

pain,  or  heat,  or  other  signs  of  inflammation.  A  lump  or  tumor 
of  considerable  size  is  often  the  first  intimation  of  glandular 
disturbance.  This  insidious  history  is  not  characteristic  of 
acute  non-specific  adenitis.  In  this  variety  of  glandular  inflam- 
mation, no  sooner  does  the  gland  begin  to  swell  than  it  becomes 
tender  and  sensitive  to  the  touch.  In  many  cases  there  is  some 
febrile  disturbance  and  there  may  be  headache  and  vomiting. 
The  gland  itself  does  not  usually  become  red  and  inflamed  on 
the  surface  until  some  days,  or  even  weeks,  have  passed.  Be- 
sides being  tender  and  sensitive  to  pressure,  it  gives  rise  to  but 
little  inconvenience.  It  is  very  subject  to  exacerbation,  one 
day  being  larger  and  more  tender,  and  the  next  day,  perhaps, 
behaving  as  if  resolution  were  progressing  rapidly.  The 
formation  of  pus,  if  it  takes  place  at  all,  does  so  very  slowly, 
and  may  threaten  many  times  before  all  hope  need  be  aban- 
doned of  its  prevention. 

Sometimes  a  single  gland  or  a  whole  string  of  glands  may  be 
affected  at  once ;  or  a  number  of  neighboring  glands  may  be 
simultaneously  involved,  and  the  whole  number  be  matted 
together  in  a  common  swelling.  When  inflammation  succeeds 
to  engorgement,  it  is  always  of  low  grade  and  the  formation  of 
pus  is  not  accompanied  by  any  of  those  symptoms  which  ordi- 
narily attend  suppuration.  It  is  for  this  reason  that  the  older 
writers  referred  to  a  suppurating  gland  as  a  "  cold  abscess." 
After  an  indolent  and- chronic  career  of  weeks,  or  sometimes 
months,  the  affected  glands  either  slowly  undergo  resolution 
and  disappear,  or  become  acutely  inflamed  and  suppurate.  In 
some  cases  the  adenitis  may  be  of  only  short  duration,  lasting 
but  a  few  days ;  but  the  tendency  is  as  stated  above,  and  the 
average  duration  is  weeks  rather  than  days. 

The  tendency  to  adenoid  inflammation  is  sometimes  met 
with  in  adults,  usually  males,  and  may,  therefore,  be  of  lifelong 
duration  ;  but  as  a  rule,  it  rarely  persists  after  puberty.  When 
occurring  in  delicate  children  in  early  life,  it  is  reasonably  safe 
to  expect  that,  with  better  health  and  the  progress  of  adoles- 
cence, the  glands  will  be  less  sensitive  and  less  liable  to  acute 
inflammation. 

Treatment. — While  the  affection  here  described  is  manifestly 
not  due  to  scrofulous  or  other  constitutional  taint  in  the  blood, 
it  is  usually  if  not  always  associated  with  more  or  less  general 
derangement  of  the  system.  It  occurs  most  frequently  in  chil- 
dren whose  digestive  organs  are  easily  disturbed,  and  who,  from 
too  rigid  confinement  indoors  or  from  constitutional  delicacy, 
are  very  subject  to  colds.  Glandular  inflammation,  too,  is 
frequently  commingled  with  some  other  disease,  as  scarlet 
fever,  measles,  diphtheria  or  other  affections  of  the  throat. 


646  THE  DISEASES  OF  CHILDREN. 

In  such  cases,  it  is  to  be  regarded  as  a  complication  and 
treated  as  such. 

When  occurring  idiopathically  or  in  connection  with  an  or- 
dinary cold,  the  treatment  should  be  more  hygienic  than  medic- 
inal. Cool  sponge  baths,  frequently  repeated,  are  very  useful. 
These  children  do  not  bear  confinement  indoors,  either  in 
school,  or  in  "apartments,"  which  are  now  so  fashionable. 
They  should  be  out  of  doors  as  much  possible,  and  be  fed  on 
coarse  but  wholesome  food.  If  there  is  such  a  thing  as  "hard- 
ening" delicate  children  by  exposure  to  the  vicissitudes  of  the 
weather,  it  should  be  judiciously  tried  in  cases  of  this  kind. 
Coddling  only  makes  matters  worse.  Exercise,  either  active 
or  passive;  a  due  regard  for  diet ;  and  plenty  of  fresh  air  are 
alone  sufficient,  in  many  cases,  to  overcome  the  tendency  to 
glandular  stenosis  and  consequent  inflammation.  When  the 
glands  do  become  swollen  and  inflamed,  they  should  be  rubbed 
with  some  warm  unguent,  like  vaselin  or  camphorated  oil. 
Even  gentle  friction  with  the  hand,  continued  for  some  minutes 
and  frequently  repeated,  will  be  found  serviceable. 

There  need  be  felt  no  fear  of  "  scattering  "  the  disease.  Such 
a  thing  is  impossible.  There  is  no  more  danger  of  such  a  re- 
sult than  there  is  of  scattering  a  mastitis,  for  the  two  affections 
are  very  similar  in  causation  and  course. 

Indeed,  the  medicinal  treatment  is  very  similar.  In  both, 
the  first  remedy  to  be  thought  of,  after  aconite,  for  the  attend- 
ant fever,  is  hepar  sulphur.  In  cases  of  chronic  character, 
with  little  or  febrile  accompaniment,  hepar,  given  three  or  four 
times  a  day,  will  often  bring  about  resolution  in  a  very  short 
time.  As  the  subjects  of  adenitis  are  usually  small  eaters,  and 
of  low  vitality,  we  are  in  the  habit  of  giving  them,  by  way  of 
a  tonic,  and  in  the  absence  of  more  clearly  indicated  homeo- 
pathic remedies,  chin,  arseniate  3x,  a  two-grain  powder  three 
times  daily,  half  an  hour  before  eating.  This  remedy  is  a 
splendid  appetizer  and  increases  the  vis  medicatrix  naturce. 
(Dther  remedies  of  value  are,  mercurius,  apocyinwt,  Phytolacca, 
thuja,  and  sulphur.  The  glands  themselves  should  never  be 
poulticed,  or  swaddled,  or  opened  with  a  lance,  until  there  are 
unmistakable  signs  of  pus  within  or  about  the  glandular 
structure. 


PART    XI. 

AFFECTIONS  OF  THE  NERVOUS  SYSTEM. 


CHAPTER    I. 
INTRODUCTION. 

Diseases  of  the  nervous  system,  especially  functional,  and 
often  organic,  might  be  prevented  by  judicious  advice  on  the 
part  of  the  physician,  followed  by  proper  care  on  the  part  of 
parents. 

As  to  attention  to  clothing,  diet  and  ordinary  sanitary  meth- 
ods, much  has  been  written  and  taught.  Physicians  are  well 
qualified  to,  and  do  advise  in  these  matters. 

We  are  not,  however,  doing  our  whole  duty  or  fulfilling  our 
responsibility,  if  we  neglect  to  make  any  effort  to  guide  parents 
in  the  training  of  their  children  in  all  respects.  We  are  apt  to 
feel  that  we  have  nothing  to  do  with  the  moral  health,  with 
the  temperament,  with  the  discipline,  or  in  fact  with  anything 
that  is  not  actual  sickness,  actual  disease.  It  is  true,  however, 
that  the  highest,  the  grandest  function  of  the  physician  is  to 
preserve  health  and  to  prevent  sickness.  There  is  no  doubt 
that  in  these  days  very  much  can  be  done  as  regards  the  spe- 
cial class  of  diseases  with  which  we  are  dealing. 

The  time  to  commence  the  prophylactic  treatment  is  soon 
after  birth.  First,  teach  the  babe  regularity  of  habits,  as  to  eat- 
ing and  sleeping ;  in  this  you  lay  a  foundation  for  self-control. 
As  the  baby  grows  there  should,  at  all  times,  be  gentle  but  firm 
•control  exercised,  insistence  on  method  and  order  in  its  little  life. 

Through  childhood  order,  method,  self-control,  thought  and 
care  as  to  the  comfort  and  feelings  of  others,  combined  with  a 
just  regard  for,  and  insistence  on,  self-comfort  and  rights,  should 
be  taught.  No  one  can  control  him  or  herself  that  has  not 
learned  to  obey  those  having  a  right  to  command. 

The  mental  development  should  always  be  under  the  general 
supervision  of  a  competent  medical  man.  The  hereditary  ten- 
dencies, mental  and  physical,  must  be  carefully  considered,  and 
the  teaching  of  the  child  regulated  accordingly.     The  child  of 

(647) 


648  THE  DISEASES  OF  CHILDREN. 

slow,  steady  nature,  with  no  predisposition  to  disease,  ought 
to  be  encouraged  in  its  natural  efforts  at  learning  from  the  very- 
beginning  of  mental  activity.  On  the  other  hand,  the  child 
who  is  at  all  predisposed  to  tuberculosis  or  struma  of  any  kind, 
or  shows  the  tendency  to  be  nervous,  should  not  be  encouraged 
in  learning.  The  child  that  is  particularly  bright  and  learns 
readily,  remembers  well,  shows  at  an  early  age  reasoning 
powers,  must  be  discouraged  in  learning.  With  this  class  of 
children,  parents  are  apt  to  claim  that  they  cannot  prevent  it. 
The  facts  are  that  they  and  their  friends,  by  oft-repeated  com- 
mendation and  praise,  stimulate  the  pride  of  the  child,  and  in 
this  way  encourage  when  they  think  they  are  trying  to  dis- 
courage. It  is  very  natural  to  be  proud  of  one's  own  child,  but 
the  wise  doctor  will  show  the  parent  the  danger,  and  the  wise 
parent  will  heed  the  warning. 

From  birth  to  puberty  develop  the  physical,  and  you  will  be 
able  to  develop  the  mental  later.  The  child  that  commences 
school  life  at  nine  years  of  age  will,  at  twelve,  usually  be  on  a 
par  in  classes  with  those  who  commence  at  six  or  seven.  The 
comprehension  of  all  that  is  taught,  instead  of  simply  using 
memory,  is  a  sufificient  explanation.  The  physician  should  see 
that  the  child,  male  or  female,  is  early  carefully  guarded  against 
pernicious  sexual  teaching,  either  by  nurses  or  companions. 
The  false  ideas  and  the  wrong  hesitancy  on  the  part  of  parents 
to  talk  with  their  children  on  these  matters,  renders  it  impera- 
tive that  the  doctor  should  see  that  it  is  not  neglected.  The 
natural  feeling  that  "  My  child  could  not  and  would  not  do  any- 
thing of  this  kind,"  makes  the  duty  of  the  medical  man,  whose 
experience  shows  him  that  no  class  escapes,  absolute  in  his 
insistence  on  watching  carefully,  as  to  the  sexual  habits  of 
children. 

Be  sure  the  baby,  and  as  it  grows  older,  the  child,  is  always 
well  and  regularly  nourished,  and  has  plenty  of  outdoor  exer- 
cise. Do  not  allow  too  much  clothing,  nor  allow  a  child  to  be 
too  thinly  clad.  See  that  houses  where  there  are  children  are 
not  made  furnaces  to  reduce  the  natural  resistance. 

GENERAL   REMARKS  AS   TO   THE   DIAGNOSIS   OF  NERVOUS 

DISEASES. 

Careful  work,  with  close  attention  to  minutia,  is  the  only 
road  to  success  in  diagnosticating  this  class  of  diseases.  In  a 
very  large  percentage  of  the  cases,  the  diagnosis  must  be  made 
by  exclusion.  Make  in  every  case  a  careful,  written  history. 
First,  as  to  any  possible  family  taint  in  any  branch  of  the  an- 
cestry, including  dissipation  of  any  kind.     Second,  as  to  any- 


DIAGNOSIS  OF  NERVOUS  DISEASES.  649 

thing  of  an  emotional  or  physical  nature  occurring  during  life 
in  utero.  Third,  as  to  the  character  of  labor,  whether  any 
occurrence  that  might  produce  injury,  rendering  the  child  sus- 
ceptible to  nerve  troubles.  Fourth,  follow  carefully  and  mi- 
nutely the  life  of  the  babe  as  to  nutrition,  sleep  and  regularity 
of  function  ;  the  kind  of  care  and  discipline  it  has  had.  Fifth, 
as  to  each  attack  of  sickness,  severity,  duration,  exact  charac- 
ter, and  the  recovery  from  each,  whether  complete  and  speedy, 
or  tardy,  and  followed  by  sequela.  Sixth,  as  to  any  injury, 
getting  all  the  particulars  as  to  how  injured ;  the  immediate 
effects,  and  possible  later  results.  Seventh,  as  to  the  very  first 
signs  of  the  trouble  for  which  you  are  consulted,  following  it 
step  by  step  very  carefully  to  the  present  time. 

Having  completed  the  history,  make  a  careful  physical 
examination  of  the  entire  body;  note  the  general  appearance, 
the  facial  expression,  the  contour  of  the  head,  the  appearance 
of  the  eyes,  as  to  size,  shape,  concordance  of  the  pupils,  and 
test  the  vision  (if  the  child  is  old  enough).  Examine  the  nasal 
passages  and  the  throat ;  auscultate  and  percuss  the  chest  and 
abdomen  carefully;  inspect  the  spinal  column  to  determine  as 
to  any  curvature  and  as  to  tenderness  over  the  spinous  pro- 
cesses ;  examine  closely  the  sexual  organs  for  any  signs  of  irri- 
tation, for  elongated  or  adherent  prepuce,  or  an  adherent 
clitoris.  Note  the  plumpness  of  the  legs  as  compared  with 
the  upper  portion  of  the  body.  Test  for  the  reflexes,  both 
superficial  and  deep.  Examine  the  anus,  and  if  there  is  any 
evidence  of  disturbance  of  the  bowels  in  the  history,  or  any 
signs  of  irritation  about  the  anus,  examine  the  rectum ;  this  is 
often  essential,  even  in  very  small  children.  An  analysis  of  the 
urine  ought  to  be  made  in  every  case.  For  this  purpose,  the 
entire  quantity  for  twenty-four  hours  should  be  collected. 
There  is  much  to  be  learned,  regarding  the  nerve  condition^ 
from  a  complete  quantitative  analysis  of  the  urine,  and,  not 
infrequently,  knowledge  that  will  lead  directly  to  the  therapeu- 
tic and  hygienic  measures  essential  to  the  speedy  cure  of  the 
case.  For  special  instruction  as  to  this  part,  you  are  referred 
to  Part  VIII. 

There  are  many  things  rendering  the  examination  of  children 
much  more  diflficult  than  of  adults.  They  are,  as  a  rule,  much 
more  emotional ;  are  unable  to  give  us  clear  and  comprehen- 
sive descriptions  of  their  feelings  ;  they  do  not  locate  sensations 
as  well,  and  are  inclined  to  exaggerations  of  expression.  Ob- 
jective symptoms  have  to  be  relied  on  to  a  great  degree.  Long 
experience  and  habits  of  close  observation  alone  can  enable  the 
physician  to  approximate  in  each  case  the  value  of  expressions 
of  pain,  or  emotional  disturbance. 


650  THE  DISEASES  OF  CHILDREN. 

Marked  irregularity  in  the  shape  of  the  head,  or  great  dispro- 
portion between  the  size  of  the  head  and  of  the  body  in  a  child, 
should  always  be  carefully  considered  with  relation  to  what 
may  be  indicated  as  to  the  future  growth  and  development, 
mentally  and  physically,  as  well  as  in  relation  to  their  signifi- 
cance in  pointing  to  a  predisposition  to  certain  diseases. 

There  are  some  special  symptoms  which  it  is  important  to 
note.  Strabismus  may  be  temporary  or  permanent.  It  is  fre- 
quently found  in  convulsive  attacks  of  every  variety  ;  if  lasting 
during  the  attack  only,  or  a  very  short  time  after,  it  is  probably 
simply  functional.  If,  however,  it  persists  for  days,  a  careful 
study  should  be  made  as  to  whether  there  is  any  abnormal 
condition  in  the  eye  itself  sufficient  to  cause  it ;  if  not,  examine 
as  to  collateral  symptoms  pointing  to  disease  of  the  brain. 

Nystagmus  may  be  found  as  a  local  chorea,  or  as  a  symptom 
of  congenital  cataract.  It  is  usually  a  result  of  cerebral  dis- 
order, such  as  tumor,  atrophy,  edema,  or  chronic  hydrocepha- 
lus. It  is  nearly  always  present  in  the  second  and  third  stages 
of  tubercular  meningitis. 

The  pupils,  if  of  unequal  size  in  a  child  with  normal  eyes 
when  in  health,  is  a  very  grave  sign  in  any  of  the  acute  cere- 
bral disorders.  If  they  respond  to  light  sluggishly,  the  indica- 
tion is  bad.  Impairment  or  loss  of  sight  is  most  common  in 
cases  of  thrombus  of  the  cerebral  sinuses,  in  meningitis  and 
intracranial  growths. 

Delirium  in  a  child  is  usually  indicative  of  some  present  or 
approaching  febrile  disturbance,  or  of  digestive  disorder  ;  but  is 
not  frequent  with  cerebral  disease,  unless  of  an  acute  inflamma- 
tory nature. 

Drowsiness  may  be  marked  in  cases  of  uremia,  or  of  digest- 
ive disturbance ;  is  very  frequently  found  to  be  the  result  of 
selfishness  on  the  part  of  the  nurse  or  mother,  shown  by  their 
administering  some  of  the  various  soothing  medicines  rather 
than  be  bothered  with  the  child.  After  a  convulsive  attack, 
drowsiness  for  an  hour  or  two  is  quite  common,  and  is  simply 
the  result  of  a  natural  reaction  from  the  excessive  muscular 
exertion  and  the  disturbance  of  circulation.  If,  however,  the 
drowsiness  is  long  persistent,  evidences  of  cerebral  disease 
should  be  looked  for  carefully.  Convulsions  occurring  fre- 
quently, with  marked  drowsiness  during  nearly  or  all  of  the 
interval,  especially  if  indications  of  head  pain  be  present,  is 
likely  to  indicate  meningitis. 

Paralysis  may  be  the  result  of  the  pressure  of  forceps  in  the 
delivery,  of  rheumatic  inflammation  of  the  sheath  of  a  nerve, 
of  lowered  general  nutrition,  of  great  prostration,  or  of  cere- 
bral, spinal,  or  peripheral  nerve  disease.    It  may  follow  convul- 


DIAGNOSIS  OF  NERVOUS  DISEASES.  651 

sive  attacks ;  if  transitory,  is  of  no  special  significance,  but  if  it 
lasts  a  number  of  days  there  probably  is  some  intracranial 
lesion  present. 

Rigidity  may  be  (especially  in  children  over  six  years  of  age) 
hysterical,  the  result  of  some  reflex  irritation,  or  of  some  spinal 
or  cerebral  disease,  acute  or  chronic.  A  long  continued  paraly- 
sis is  quite  certain  to  be  followed  or  accompanied  by  a  perma- 
nent rigidity  and  contraction.  The  rigidity  of  the  muscles  of 
the  neck,  drawing  the  head  back  between  the  shoulders,  so  fre- 
quent a  symptom  in  various  forms  of  meningitis,  if  at  all  well 
marked,  is  a  very  serious  indication. 


CHAPTER  II. 

CONVULSIONS  IN  CHILDREN. 

Convulsions  may  occur  at  any  age.  In  fetal  life  they  are 
not  common,  but  it  is  probable  that  they  are  the  cause  some- 
times of  death  in  utero.  Attacks  during  the  first  week  or  two 
following  birth  are  probably  the  result  of  injury  to  the  brain 
by  pressure  during  labor,  whether  it  be  natural  or  instrumental, 
or  of  uremia  in  the  mother.  They  are  frequent  during  the  first 
two  years  of  life,  and  from  this  time  on  grow  less  frequent  to 
old  age.  They  are,  I  believe,  always  the  result  of  irritation  of 
some  portion  of  the  central  nervous  system.  Many  theories 
have  been  advanced  and  experiments  made  to  determine  an 
exact  center,  and  the  definite  character  of  the  nerve  action  ;  but 
up  to  this  time  with  indifferent  success.  The  disturbance  of 
the  animal  electrical  poise,  anemia  of  the  brain,  explosion  of 
nerve  force,  vaso-motor  irritation  or  paresis,  defective  cerebral 
nutrition  from  any  cause,  have  all  been  advocated  by  men  of 
large  learning  and  special  skill  in  this  particular  line  of  study. 
There  is  one  point  on  which  I  think  all  can  agree,  viz.:  that  by 
some  as  yet  undetermined  process  the  inhibitory  powers  of  the 
higher  cerebral  functions  are  interfered  with,  and  as  a  result  of 
this  loss  of  control,  motor,  sensory,  and  vaso-motor  centers  act 
without  coordination,  producing  violent,  irregular  contractions 
of  muscles,  occurring  in  paroxysms,  often  with  insensibility. 

There  is  in  these  cases  a  predisposition  to  convulsions,  a 
neuropathic  temperament.  It  is  claimed  by  many  authorities 
that  rachitis  is  the  most  common  cause.  My  own  experience 
will  hardly  justify  such  a  conclusion.  Rachitic  children  are 
quite  liable  to  attacks,  and  a  large  majority  do  have  convul- 
sions ;  but  I  have  seen  many  more  cases  where  various 
stomachic  and  intestinal  irritations  are  the  undoubted  cause. 
Worms,  chiefly  lumbrici  —  tape  worms  being  very  uncommon 
in  young  children  —  and  thread  or  pin  worms,  are  a  frequent 
cause.  Articles  of  diet  that  are  particularly  indigestible  or 
irritating  to  the  gastro-intestinal  mucous  membrane,  or  more 
or  less  completely  impacted  fecal  matter,  may  also  produce  " 
convulsions.  Irritation  of  the  genito-urinary  organs,  various 
states  of  the  blood,  as  uremia,  and  as  found  at  the  beginning 
of  many  febrile  attacks,  and  passive  congestion  of  the  brain^ 
(652) 


CONVULSIONS  IN  CHILDREN.  653 

are  common  etiological  factors.  It  is  now  claimed  that  active 
arterial  congestion  is  never  the  cause  of  convulsive  attacks. 
General  exhaustion  from  any  cause,  a  profuse  and  lasting 
diarrhea,  are  possibly  the  most  common  causes,  as  are  also 
sudden  and  violent  emotions.  The  hydrocephaloid  condition 
and  external  irritants  to  any  part  of  the  body,  and  lowered 
nutrition,  from  whatever  cause,  will  render  the  child  addition- 
ally susceptible. 

The  cases  due  to  intracranial  lesions,  which  may  occur  at  any 
age,  may  be  considered  under  their  respective  headings. 

It  is  not  at  all  uncommon  for  the  parents  to  declare  that  the 
first  attack  came  on  without  any  previous  indication  or  imme- 
diate cause  whatever.  By  careful  inquiry,  the  physician  will 
nearly  always  find  that  for  some  hours  or  days,  possibly  weeks, 
the  child  has  been  unusually  nervous  and  irritable,  or  it  may 
have  been  uncommonly  quiet  and  inclined  to  languor.  Possi- 
bly little  twitchings  of  the  various  muscles  of  the  face,  hands, 
or  lower  extremities  were  present.  In  some  cases  slight 
spasms  of  a  local  character  have  occurred  a  number  of  times. 
I  believe  in  very  nearly  all  cases  you  will  be  able  to  learn  of  a 
more  or  less  marked  deviation  from  the  ordinary  characteristics 
of  the  child.  In  the  cases  due  to  gastro-intestinal  irritation 
from  overloading  the  stomach,  or  from  improper  food,  there 
will  not  usually  be  marked  pain  in  the  stomach  or  bowels.  If 
the  irritation  vents  itself  in  local  pain  there  is  not  likely  also 
to  be  reflex  irritation. 

The  attack  itself  is  likely  to  be  first  a  paleness  of  the  face,  a 
rolling  of  the  eyeballs  upward,  outward,  inward,  or  downward, 
followed  by  a  stiffening  of  the  body  in  tonic  spasm.  There 
may  be  opisthotonos  or  simple  retraction  of  the  head,  or  roll- 
ing of  the  head  to  one  or  the  other  side ;  hands  may  be 
clinched  or  opened  widely,  feet  straightened  out  or  drawn  to 
the  right  or  left  side.  This  will  be  accompanied  by  a  flushing 
of  the  face,  changing  to  a  bluish  or  purplish  hue  ;  more  or  less 
difficulty  of  respiration.  Following  there  may  be  a  relaxation 
of  the  contractions,  or  clonic  spasms  continuing  for  a  short 
period,  then  gradually  growing  less  pronounced  until  perfect 
relaxation,  and  followed,  usually,  by  a  sleep  of  varying  dura- 
tion ;  preceding  the  sleep  there  is  a  return  of  natural  color  to 
the  face  and  one  or  more  long,  deep  inspirations.  All  cases  do 
not  present  this  entire  picture ;  there  may  be  anything  from 
the  simple  rolling  of  the  eye  to  the  full  attack.  When  the 
child  awakens,  it  often  appears  to  be  perfectly  well;  but  when 
the  attack  is  due  to  any  immediate  and  temporary  irritation, 
there  will  still  be  found  present  some  evidences  of  such  cause. 

It  will  not  always  be  possible  to  determine  at  once  whether 


654  THE  DISEASES  OF  CHILDREN. 

there  is  present  a  true  epilepsy,  some  organic  brain  lesion,  the 
ushering  in  of  some  acute  disease,  the  result  of  some  constantly- 
acting  irritant,  or  an  immediate  and  temporary  irritation. 
Differentiation  from  true  epilepsy  is  impossible  when  occur- 
ring in  a  very  young  child,  or  if  this  is  the  first  attack.  In  a 
child  not  over  two  years  of  age,  who  is  thoroughly  well  nour- 
ished, quite  fat  and  robust,  it  is  almost  certainly  reflex.  On 
the  contrary,  if  emaciated  and  poorly  nourished,  a  tubercular 
condition  may  be  suspected.  If  a  brain  lesion  be  present,  the 
convulsion  is  apt  to  be  partial ;  one  arm  or  one  leg  only  being 
affected,  often  a  paralysis  of  facial  muscles,  remaining  a  short 
time,  producing  ptosis,  drawing  of  the  mouth,  inequality  of  the 
pupils,  or  a  general  paralysis  persisting  for  many  hours  or  days. 
A  strabismus,  although  not  necessarily  indicative,  yet  if  at  all 
persistent,  not  having  been  present  before  the  convulsion,  de- 
serves careful  attention  as  to  collateral  evidences  of  brain  lesion. 
If  there  be  no  loss  of  consciousness,  and  stupor  or  great  drow- 
siness remains  many  hours  or  days,  especially  if  accompanied  by 
muscular  contractions,  there  is  good  reason  to  fear  intracranial 
lesion.  It  is  not  common  to  have  a  convulsion  occur  as  one  of 
the  first  evidences  of  an  acute  disease,  yet  some  children  are  so 
susceptible  to  slight  irritations  that  an  attack  seems  to  replace 
the  chill  which  so  frequently  ushers  in  the  disease ;  in  these 
cases,  the  evidences  of  febrile  disturbance,  and  the  immediate 
subsequent  history,  will  solve  the  problem.  Much  more  fre- 
quently we  have  convulsions  in  the  late  stages  of  acute  diseases ; 
they  are  then  always  of  serious  import.  If  the  gums  are  hard, 
inflamed  and  swollen,  and  there  is  some  febrile  disturbance,  it 
is  probably  due  to  dental  irritation. 

If  there  is  any  discoverable  irritation,  it  is  reasonable  to  con- 
clude that  it  is  a  case  of  eclampsia.  Always  examine  the  urine. 
Children  very  often  have  uremic  convulsions. 

The  prognosis  in  all  but  the  purely  eclamptic  or  reflex  cases 
will  be  considered  in  other  connections.  In  those  of  reflex 
origin,  it  depends  upon  the  possibility  or  probability  of  remov- 
ing the  cause.  If  the  fit  be  very  severe  and  of  long  duration,  there 
is  danger  that  emboli,  thrombus,  congestion,  or  effusion  may 
occur  as  a  result  of  the  convulsion.  In  babes  of  a  few  weeks 
this  is  very  likely  to  occur,  death  ensuing  apparently  as  a  direct 
result  of  the  convulsion.  If  the  patient  is  very  much  exhausted 
from  acute  disease,  or  very  poorly  nourished  from  any  cause,  a 
fatal  result,  while  not  inevitable,  is  to  be  feared.  If  a  convul- 
sion, or  series  of  them,  occur  in  a  later  stage  of  any  of  the 
acute  febrile  diseases,  death  is  very  probable.  Marked  sterto- 
rous breathing,  rapid  pulse,  or  a  very  pale,  livid  countenance 
indicates  danger.     If  there  be  very  scant  excretion  of  urine. 


CONVULSIONS  IN  CHILDREN.  655 

there  is  serious  danger,  unless  a  copious  flow  of  urine  of  good 
quality  in  a  reasonably  short  time  can  be  excited. 

In  considering  the  prognosis  of  convulsive  seizures,  it  must  be 
remembered  that  many  cases  of  imbecility  from  arrested  cere- 
bral development  are  due  to  convulsions,  in  which  we  are 
unable  to  find  any  brain  lesion.  In  ordinary  attacks  the 
result  of  reflex  irritation,  or  in  rickety  children,  no  such  re- 
sult is  to  be  expected,  unless  the  attacks  are  not  only  very 
frequent,  but  of  long  duration,  and  followed  by  marked  mus- 
cular weakness,  paresis,  or  long-continued  coma  or  somno- 
lence, showing  immediate  cerebral  affection  as  a  consequence 
of  the  fit. 

It  is  not  often  that  the  physician  arrives  in  time  to  find  the 
patient  actually  in  the  fit.  When  he  does,  the  most  important 
thing  is  to  preserve  a  calm,  well-poised  demeanor,  and  without 
unseemly  haste  direct  the  various  persons  about,  to  prepare  a 
warm  bath,  to  undress  the  child,  procure  cold  water,  blankets, 
towels,  etc.  It  is  not  a  very  difficult  matter  usually  to  give 
each  person  present  something  to  do,  and  in  this  way  it  is  quite 
possible  in  most  cases  to  secure  a  quiet  atmosphere  about  the 
patient,  the  physician  himself  keeping  a  careful,  observant 
eye  on  the  patient,  watching  the  exact  character  of  the  fit  with 
reference  to  the  presence  or  absence  of  marked  indications  of 
cerebral  lesion.  If  the  fit  has  not  ceased  by  the  time  the  bath 
is  prepared,  immerse  the  body  from  the  neck  down  in  the  warm 
or  hot  bath,  and  apply  cold  water  to  the  head.  The  water 
should  be  quite  warm,  almost  hot,  but  be  careful  that  it  is  not 
hot  enough  to  scald.  I  do  not  give  exact  temperature,  as  it  is 
unnecessary.  Nearly  always  the  attack  will  cease  in  a  very 
few  minutes.  Ordinarily,  the  child  may  be  left  in  the  bath  ten 
or  fifteen  minutes,  but  if  very  much  exhausted  from  previous 
sickness,  or  very  poorly  nourished,  not  more  than  from  two  to 
five  minutes.  These  baths  may  be  repeated  at  frequent  inter- 
vals, if  found  necessary.  The  bowels  should  always  be  com- 
pletely emptied  with  an  enema  ;  and  if  soon  after  eating,  empty 
the  stomach  by  an  emetic.  When  taken  out  of  the  bath,  the 
child  should  be  wiped  dry  quickly,  placed  in  bed  and  covered 
carefully,  in  a  room  well  ventilated  and  not  too  Hght.  If  the 
child  is  of  teething  age,  examine  the  gums  carefully,  and  lance 
them  if  swollen  and  tense ;  in  short,  see  that  all  immediate 
irritation  is  removed. 

A  dose  of  castor  oil  will  clear  up  a  case  very  speedily,  if  large 
and  small  intestines  are  loaded  with  any  irritating  accummula- 
tion.  It  will  sometimes  be  found  necessary  to  administer 
chloroform  by  inhalation,  in  order  to  stop  the  convulsions, 
or  to   prevent  immediate  and  frequent  recurrence.     It  often 


656  THE  DISEASES  OF  CHILDREN. 

happens  that  the  immediate  irritant  cannot  be  speedily  re- 
moved, and  there  is  danger  of  serious  trouble  ensuing  from  the 
frequency  and  severity  of  the  convulsive  attacks ;  in  these 
cases,  I  advise  the  giving  of  a  mixture  of  sodium  brornid  and 
chloral  hydrate.     The  formula  is : 

Sodium    bromid grs.  40 

Chloral    hydrate grs.  i6 

Aqua  distil q.  s.  5'^. 

Mx. 
Sig. :  Give  a  tablespoonful  once  every  hour  or  two,  till  relieved. 

The  remedies  to  be  used  at  this  time  are,  aconite,  calcarea 
carb.,  c  amp  hot  mono -br  omat  e ,  gelsemium,  santofiin,  or  veratrum 
viride.  The  physician  having  the  family  in  charge  does  not 
do  his  duty  if  he  fails,  in  every  case  to  which  he  is  called,  to 
make  careful  inquiry  and  examination  for  the  cause  of  the 
particular  attack,  and  as  to  whether  or  not  there  have  been 
previous  attacks. 

The  treatment  of  recurring  cases  will  be  considered  in  con- 
nection with  epilepsy. 

EPILEPSY. 

Epilepsy  is  a  condition  of  more  or  less  marked  loss  of  con- 
sciousness, recurring  at  regular  or  irregular  intervals,  with  or 
without  convulsions,  not  caused  by  immediate  irritation,  and 
where  the  pathological  condition  producing  the  attacks  is 
unknown. 

This  definition  excludes  a  very  large  percentage  of  the  cases 
usually  diagnosed  as  epilepsy.  For  practical  purposes,  the 
only  objection  to  calling  all  cases  of  the  epileptic  class  by  the 
one  term,  is  the  tendency  on  the  part  of  the  physician  to  be 
satisfied  with  a  diagnosis  of  epilepsy,  and  to  prescribe  for  all 
cases  their  peculiar  or  special  epileptic  treatment. 

If,  by  any  means,  the  physician  can  be  induced  to  consider 
the  attacks  simply  as  symptomatic,  and  to  feel  that  he  has  not 
made  a  diagnosis  of  the  case  until  he  has  ruled  out  all  possible 
sources  of  irritation,  the  prognosis  of  this  disease  or  condition 
will  be  very  much  brighter,  and  the  percentage  of  cures  can 
certainly  be  made  much  larger  than  at  present.  There  are 
many  curable  cases  allowed  to  go  uncured  simply  because  they 
are  called  epilepsy  and  no  careful  investigation  made.  If  we 
shall  be  able  to  make  it  plain  that  a  disease,  whatever  its  symp- 
toms, is  never  correctly  named  except  by  its  pathology,  very 
much  will  be  gained.  Thus,  if  we  have  a  case  presenting  the 
ordinary  phenomena  of  epilepsy,  and  find  that  it  is  due  to  eye- 


E  PILE  PS  2'.  657 

strain — a  hyperphoria,  for  instance — the  diagnosis  should  be,  not 
epilepsy,  but  hyperphoria.  I  do  not  claim  that  the  present 
authorities  have  been  in  error  in  including  so  many  and  diverse 
pathologies  under  the  one  head  epilepsy,  nor  do  I  believe  the 
thoroughly  scientific  specialist  has  overlooked  the  special  pathol- 
ogy in  his  individual  cases  ;  but  I  do  believe  the  general  practi- 
tioner, whose  time  is  fully  occupied,  will  get  much  better  results 
by  this  classification.  The  prognosis  in  pure  epilepsy  depends 
in  the  main  on  the  character,  frequency  and  severity  of  the 
attacks.  Many  patients  will  have  quite  severe  and  frequent 
attacks  for  many  years,  with  very  little  apparent  effect  on  the 
general  health,  The  constant  fear  of  an  attack  must,  of  course, 
have  a  tendency  to  mental  depression,  and  so  in  a  measure 
unfit  the  subject  for  the  ordinary  duties  of  life.  It  is  true  that 
many  epileptics  are  apparently  bright,  perfectly  able  to,  and 
do  engage  in  various  vocations,  but  the  frequent  recurrence  of 
attacks  does,  in  a  very  large  majority  of  cases,  cause  a  corres- 
ponding loss  of  mentality.  In  many  subjects  there  is,  accom- 
panying each  convulsive  attack,  an  actual  insanity,  lasting  from 
a  few  minutes  to  some  hours.  There  are  a  few  cases  in  which 
more  or  less  frequent  attacks  of  acute  mania  occur  at  intervals, 
and  are  of  short  duration,  the  patient  apparently  being  per- 
fectly sound  mentally  between  attacks,  and  with  no  loss  of 
consciousness  or  evidences  of  spasms ;  these  attacks,  although 
there  are  no  convulsions,  must  be  considered  as  epilepsy,  un- 
less it  is  possible  to  discover  a  sufficient  pathology.  There  is 
always  a  liability  to  idiocy,  imbecility,  or  some  form  of  mental 
incapacity  from  defective  nutrition  of  the  brain,  resulting  from 
the  disturbance  of  circulation.  In  a  small  percentage  of  cases, 
pathological  lesions  of  various  kinds  are  the  direct  result  of  the 
circulatory  disturbance  of  the  brain. 

Death  as  a  direct  result  of  epilepsy  is  not  very  common,  the 
patient  usually  dying  from  some  other  cause. 

Attention  should  always  be  called  to  the  danger  from  acci- 
dent in  falling  while  in  the  fit. 

The  percentage  of  cures  in  pure  epilepsy,  after  all  the  con- 
vulsive cases  caused  by  known  pathologies  are  ruled  out,  under 
any  method  of  treatment  will  be  small ;  but  I  believe  under  the 
homeopathic  law  carefully  applied,  there  is  a  very  decided 
favorable  margin  as  against  the  anti-spasmodic  methods.  In 
the  treatment  of  recurrent  convulsions,  the  closest  attention 
must  be  given  to  every  detail  in  the  environment  and  habits  of 
the  patient,  and  the  remedy  must  be  selected  with  the  greatest 
accuracy. 

Where  the  attacks  are  the  result  of  any  reflex  irritation,  this 
must  be  removed  at  the  earliest  possible  moment.  For  in- 
D.  C— 42 


658  THE  DISEASES  OF  CHILDREN. 

Stance,  many  cases  resulting  from  stomach  worms  have  been 
permanently  cured  by  five-grain  doses  of  scale  pepsin  every 
two  hours.  The  pepsin  should  be  put  in  capsules.  This 
dose  can  be  given  to  children  over  three  years  of  age,  while 
for  younger  children  the  dose  should  be  from  two  to  three 
grains. 

Whenever  a  source  of  irritation  is  found,  lose  sight  of  the 
one  symptom,  convulsion,  and  cure  the  cause,  whether  it  be  by 
the  administration  of  medicine,  by  operative  interference,  or 
by  correction  of  eye  condition.  The  long  or  adherent  prepuce 
should  always  be  promptly  excised,  the  adherent  clitoris  liber- 
ated, and  the  constricted  urethra  or  meatus  relieved.  Do  not 
fail  to  note  and  correct  any  malposition  of  testicles  or  ovaries, 
even  in  small  children.  Correct  as  soon  as  possible  any  defect 
in  refraction  with  glasses,  and  be  very  careful  to  correct  fully 
any  muscular  deficiency  in  the  eye.  While  the  various  hetero- 
phorias  are  not  by  any  means  the  cause  of  all  cases,  they  are  in 
a  large  number,  and  many  can  be  cured  by  either  the  prisms 
or  by  operation.  Fissures  in  the  rectum  and  anus  are  much 
more  common  in  children  than  is  ordinarily  understood,  and 
must  be  cured  at  once. 

If  the  child  has  received  an  injury  at  any  time,  very  careful 
inquiry  as  to  its  possible  location  on  the  head,  and  also  as  to 
the  effects  or  condition  immediately  following  the  injury  should 
be  made.  The  head  must  be  carefully  and  minutely  examined 
over  the  entire  surface,  to  ascertain  the  presence  or  absence  of 
any  evidence  pointing  to  a  depression  at  any  point.  If  there 
is  a  clear  case  of  an  injury  on  the  head,  followed  by  severe 
symptoms,  such  as  might  be  the  result  of  concussion  or  frac- 
ture, and  in  addition  to  this  there  is  found  at  the  point  of  injury 
a  depression,  no  doubt  should  be  entertained  as  to  the  proced- 
ure ;  operate  at  once.  I  would  like  here  to  caution  the  physi- 
cian as  to  the  necessity  of  examining  very  carefully  for  evidences 
of  cranial  injury  when  called  to  see  any  child  who  has  had  an 
accident.  There  are  a  great  many  epileptics,  as  well  as  mental 
deformities  and  insufficiencies,  that  could  have  been  prevented, 
had  the  physician  who  saw  the  case,  at  the  time  of  the  acci- 
dent, given  it  a  proper  examination. 

If  the  convulsions  are  unilateral,  or  always  begin  in  the  same 
set  of  muscles,  and  if  they  become  general ;  or  if  the  spasm  is 
very  much  more  marked  in  some  one  set  of  muscles ;  or  if  a  certain 
set  of  muscles  are  paretic  or  atrophied,  or  markedly  weakened, 
and  it  is  impossible  to  find  any  sufficient  source  of  reflex  irrita- 
tion, the  skull  should  be  opened  at  the  center  for  motion  of  the 
affected  muscles,  and  a  careful  scrutiny  made  of  the  outer  and 
inner  table  of  the  skull,  and  of  the  membranes,  and  if  nothing 


EPILEPSr.  659 

be  found  in  these  parts,  examine  deeper  in  the  brain  for 
abnormal  conditions. 

If  there  is  a  history  of  cerebritis  in  early  life,  and  a  slow 
mental  development,  or  if  the  fontanels  closed  very  early,  the 
general  contour  of  the  skull  should  be  carefully  considered 
with  reference  to  uneven  or  irregular  development,  or  an  insuf- 
ficient development  and  expansion  of  the  cranium,  and  in  the 
absence  of  other  cause  for  the  attacks,  a  piece  of  bone  may  be 
removed  for  the  purpose  of  allowing  expansion,  and  in  this  way 
relieve  pressure  of  the  brain  from  a  proportionately  too  small 
calvaria.  The  habit  of  operating,  however,  except  in  such 
cases  as  indicated,  where  there  are  well-marked  evidences  for  the 
localized  lesion,  is  not  to  be  recommended. 

A  full  quantitative  analysis  of  the  twenty-four  hours'  urine 
should  always  be  made.  A  goodly  number  of  cases  will  be 
found  in  which  there  is  a  marked  deficiency  in  the  excretion  of 
urea.  If  this  low  excretion  of  urea  is  regular  and  continuous 
for  some  considerable  time,  and  there  are  no  evidences  of  reflex 
irritation,  it  is  possibly  a  chronic  uremic  poisoning,  and  must 
be  treated  accordingly.  In  some  subjects,  there  will  be  found 
a  regular,  continuous,  low  excretion  of  phosphoric  acid,  which 
probably  indicates  deficient  oxidation  of  phosphorus  in  the  sj^s- 
tem  and  may  excite  sufficient  irritation  to  require  special 
treatment. 

In  the  treatment  of  epilepsy,  and  of  all  recurring  convulsions, 
moral  control  is  of  the  greatest  importance.  The  child's  life 
should  be  regulated  with  the  closest  attention.  Gentle,  but 
firm  and  regular  discipline  should  be  constantly  preserved. 
There  must  be  a  preponderance  of  quiet,  and  as  much  freedom 
from  excitement  of  any  kind  as  possible.  The  emotional  ele- 
ment must  not  be  stimulated;  everything  that  is  likely  to 
produce  strong  emotion  of  any  kind  should  be  avoided  and 
guarded  against. 

The  life  should  not,  however,  be  idle,  but  as  full  of  interest 
in  objects  outside  of  the  child's  own  personality  as  is  possible, 
without  in  any  way  straining  the  nervous  forces.  It  is  often 
very  essential  that  the  physician  devise  ways  and  means  for 
the  amusement  and  occupation  of  his  patient.  If  there  be  any 
tendency  to  any  form  of  immorality,  the  child  should  be  gently 
led  by  the  strongest  influences  it  is  possible  to  bring  to  bear,  to 
a  right  kind  of  thinking.  Every  person  must  be  studied  as  an 
individual,  in  order  to  know  just  what  line  of  argument  or  of 
action  will  be  the  most  influential,  as  to  just  what  environments 
will  be  most  potent  for  good. 

There  is  no  class  of  cases  in  which  I  spend  as  much  time  and 
study  in  the  selection  of  a  remedy  as  in  the  pure  epilepsies.     I 


t>60  THE  DISEASES  OF  CHILDREN. 

know  that  if  I  can  find  the  similimum,  there  is  a  reasonable 
hope  of  a  cure.  My  method  of  study  is  to  select  some  one 
symptom  that  is  most  constant  and  uniform  during  the  time  be- 
tween the  attacks,  and  also  one  in  immediate  connection  with 
the  attack.  If  possible,  I  find  some  symptom  that  is  always 
present,  and  another  that  comes  with  every  attack,  then  look 
for  a  remedy  or  remedies  having  one  or  both  of  these  symptoms. 
I  next  look  for  a  remedy  or  remedies  covering  any  dyscrasia, 
and  one  covering  the  general  temperament,  then  for  those 
with  like  aggravations  or  ameliorations,  I  make  a  list  of  the 
remedies  so  selected,  and  opposite  each  one  a  tally-mark  for 
every  symptom  common  to  it  and  my  case.  My  experience  has 
been  that  I  get  good  results  from  the  higher  potencies  in  these 
pure  epilepsies  more  uniformly  than  from  the  low.  I  continue 
the  remedy  selected  for  months,  and  sometimes  for  years.  In 
the  reflex  convulsions  I  use  the  lower  potencies  more  frequently 
than  I  do  the  higher. 

Never  forget,  under  any  circumstances,  that  any  and  every 
possible  source  of  irritation  must  be  removed  as  soon  as 
possible. 

The  entire  materia  tnedica  is  the  list  of  remedies  from  which 
the  indicated  remedy  must  be  selected.  The  following  are 
among  those  possibly  most  frequently  found  to  be  indicated  : 
Absinthium,  athusa  cyn.,  agaricus,  ammonium  carb.,  amy  I 
nitrite,  argentum  chL,  arsenicum  alb.,  belladonna,  bufo,  calcarea 
carb.,  calcarea  phos.,  camphora,  cannabis  ind.,  causiicum,  cedron, 
chinium  ars.,  ciciita  vir.,  cimicifuga,  cuprum  acet.,  cypripediam, 
gelsemium,  glonoin,  hydrocyanic  acid,  hyoscyamus,  hypericum, 
ignatia,  kali  brom.,  kali  carb.,  kali  phos.,  lachesis,  magnesia  phos., 
moschus,  nitric  acid,  nux  vom.,  cenanthe  croc,  platinum,  plum- 
bum, silicia,  stannum,  staphisagria,  stramonium,  sulphur,  viscum 
alb.,  veratrum  album,  verairum  viride,  and  the  zincs. 

It  would  not  be  right  to  neglect  some  attention  to  the  treat- 
ment used  in  other  schools  of  medicine,  and  to  palliative 
measures. 

There  are  cases  in  which  it  seems  absolutely  necessary  to 
overpower  the  convulsive  attacks,  temporarily  at  least.  Per- 
manent cures  have  resulted  from  the  administration  of  power- 
ful antispasmodic  remedies. 

For  many  years  the  bromides  have  been  probably  the  main 
reliance  of  the  majority  of  the  medical  profession.  The  va- 
rious bromides  are  used,  the  particular  one  being  dependent 
usually  on  the  individual  preference  of  the  physician  in  attend- 
ance. Mixtures  of  bromid  and  chloral  hydrate  are  often  used. 
I  do  not  propose  here  to  discuss  the  bromid  treatment.  The 
dose  for  a  child  ranges  from  three  to  ten  grains,  repeated  from 


EPILEPSr.  661 

three  to  four  times  a  day.     It  is  better  to  give  it  in  milk  or  a 
considerable  quantity  of  water. 

Chloral  hydrate  may  be  given  to  children  in  from  two  to  five 
grain  doses,  or  a  mixture  in  which  each  dose  shall  consist  of 
from  five  to  ten  grains  of  one  of  the  bromides,  and  from  two  to 
five  grains  of  chloral  hydrate.  Inhalation  of  amyl  nitrite,  a 
few  drops  on  a  handkerchief,  immediately  on  the  appearance 
of  an  aura,  will  often  prevent  an  attack. 


CHAPTER    III. 

CHOREA   (ST.  VITUS'    DANCE). 

Definition. — Chorea  is  an  affection  of  the  nervous  system  of 
uncertain  origin,  affecting,  for  the  most  part,  children  between 
the  ages  of  six  and  thirteen,  and  characterized  by  erratic,  invol- 
untary, and  uncontrollable  twitchings  or  jerkings  of  certain 
muscles,  or  groups  of  muscles,  which  are,  however,  as  a  rule, 
quiescent  during  sleep. 

It  may  be  partial  or  general — unilateral  or  bilateral — affect- 
ing only  a  single  group  of  muscles,  or  implicating  every  volun- 
tary muscle  in  the  body. 

It  may  be  sub-acute  or  chronic,  but  is  usually  neither  painful 
nor  dangerous.  The  patient  is  not  deprived  of  either  volition 
or  consciousness,  nor  is  the  disease  attended  with  fever.  The 
French  call  \X.  folie  niusculaire,  or  "insanity  of  the  muscles." 

When  the  spasmodic  movements  are  confined  to  one  side, 
the  affection  is  called  hemi-chorea;  when  paralysis  is  associated 
with  it,  chorea  paralytica;  and  when  the  chorea  follows  a  paral- 
ysis, it  is  called  post-paralytic  chorea.  This  last  is  very  similar 
to  paralysis  agitans. 

Etiology. — There  is  no  fixed  or  universal  cause  for  chorea. 
In  one  case  the  disease  may  have  a  central  and  in  another  a 
reflex  origin. 

It  may  arise  from  some  organic  and  incurable  disease  of  the 
brain  or  spinal  cord,  or,  on  the  other  hand,  it  may  be  caused 
by  a  purely  functional  derangement  of  some  nerve  center  or 
peripheral  nerve  branch.  Cases  have  been  recorded,  in  which 
an  immediate  cure  was  effected  by  the  removal  of  a  tape  worm, 
or  the  root  of  a  diseased  tooth. 

The  disease  is  so  commonly  associated  with  rheumatism  that 
the  latter  is,  by  some  authorities,  considered  an  almost  neces- 
sary concomitant  of  chorea.  It  is  a  well-established  fact  that 
chorea,  like  rheumatism,  is  most  prevalent  in  the  spring,  and 
in  damp  climates,  and  that  the  heart  lesions  of  rheumatism  are 
also  observed  very  commonly  in  the  victims  of  chorea.  But, 
on  the  other  hand,  there  is  no  constancy  in  the  association  of 
the  two  diseases,  and  many  severe  cases  of  chorea  have  been 
observed  in  which  there  was  neither  rheumatic  nor  cardiac 
complications. 
(662) 


CHOREA   {ST.  VITUS'  DANCE).  -         663 

Girls,  whose  nervous  system  is  proverbially  more  impression- 
able than  that  of  boys,  are  affected  with  chorea  more  often 
than  the  latter— the  proportion  of  victims  being  generally 
stated  as  five  to  two. 

In  very  many  instances,  fright  has  been  clearly  recognized  as 
the  exciting  cause.  Any  sudden  mental  shock  or  intense  emo- 
tion may  develop  an  attack,  in  a  previously  healthy  child  of 
nervous  organization. 

The  inherent  power  of  imitation  is  held  responsible  for  those 
occasional  epidemics  of  chorea  which  have  been  frequently 
observed  in  boarding  schools,  where  a  number  of  impression- 
able youth  are  assembled  together.  No  one  has  observed  any 
special  tendency  to  hereditary  transmission  of  the  disease. 

In  many  cases,  the  affection  so  closely  resembles  hysteria  as 
to  be  indistinguishable  from  it. 

Among  the  predisposing  causes  of  chorea  are  scarlet  fever, 
measles,  and  diphtheria;  indeed,  any  disease  which  lowers  the 
tone  of  the  system,  may  lead  up  to  an  attack  of  chorea.  Girls 
affected  with  chlorosis,  anemia,  dysmenorrhea,  or  amenorrhea, 
are  very  prone  to  this  affection.  Overstudy,  bad  air,  bad  food, 
anything,  in  fact,  which  interferes  with  full  nutrition,  and  a 
perfect  state  of  general  health,  may  be  regarded  as  a  cause — 
near  or  remote — of  this  perverted  condition  of  the  nervous 
system. 

Dr.  Worcester  states  that  an  investigation  in  regard  to  its 
occurrence  among  school  children,  showed  that  over  twenty  per 
cent,  of  the  young  children  in  the  public  schools  of  New  York 
are  troubled  with  choreic  affections  of  greater  or  less  gravity. 
These  varied  from  slight  movements  of  the  hands  and  twitch- 
ing of  the  facial  muscles  to  such  as  attracted  the  notice  of  vis- 
itors. In  some  cases  the  disturbance  of  the  nervous  system 
which  causes  the  outbreak,  is  not  of  a  mental,  but  of  a  reflex 
nature,  owing  to  some  peripheral  irritation  spreading  to  the 
nerve  centers. 

The  fact  that  girls  are  more  often  affected  just  prior  to  pu- 
berty, or  at  the  time  when  the  organism  is  undergoing  those 
preparative  changes  which  precede  menstruation,  is  strongly 
indicative  of  the  reflex  character  of  the  exciting  cause,  and 
places  the  affection  in  the  category  of  reflex  neurosis. 

Pathology. — From  what  has  already  been  said,  it  is  apparent 
that  chorea  is  rather  a  symptom  than  a  dxsedise  per  se;  the  irreg- 
ular and  erratic  explosions  of  nerve  force  which  characterize 
its  manifestations  may  depend  upon  organic  changes  in  the 
corpus  striatum  and  thalamus,  or  to  hyperemia  or  anemia 
of  nerve  centers;  or,  as  maintained  by  some,  the  disturbance 
may  be  due  to  capillary  embolisms.     All  of  these  hypotheses 


664  THE  DISEASES  OF  CHILDREN. 

have  been  discussed,  and  in  the  few  fatal  cases  which  have  been 
investigated,  all  of  them  have  been  found  partial  verifications. 
But  in  spite  of  this,  and  after  all  is  said,  chorea  has  no  morbid 
anatomy ;  "  there  is  no  one  lesion  of  constant  standing,  save 
the  fungi  of  vegetations  which  occupy  the  edges  of  the  aortic 
and  mitral  valves  ;  but  endocarditis,  in  the  form  of  vegetations, 
is  present  in  the  greater  number  of  cases." 

Goodhart  states  that,  "  Of  the  fatal  cases  already  recorded 
(thirty  in  all),  these  were  present  in  twenty-eight,  doubtful  in 
one,  and  absent  certainly  only  once.  Their  absence  is  quite 
the  exception.  The  mitral  was  affected  alone  fifteen  times ; 
both  aortic  and  mitral  valves,  nine  times ;  the  aortic  valves 
alone  four  times ;  and  pericarditis  occurred  with  the  endocar- 
ditis six  times. 

"  The  constancy  of  these  little  growths  upon  the  edges  of  the 
valves  has  led  to  a  very  direct,  simple,  and  fascinating  pathol- 
ogy for  chorea,  in  the  suggestion  that  it  is  due  to  embolism. 
The  vegetations  are,  it  is  supposed,  washed  off  the  valves  and 
carried  into  the  smaller  branches  of  the  cerebral  arteries,  and 
thus  produce  local  anemia,  malnutrition,  and  degeneration  of  the 
cerebral  cortex  and  ganglia,  which  lead  to  the  loss  of  controL 
over  the  muscles." 

This  view  of  the  pathology  of  chorea,  while  ingenious  and 
probably  true  of  many  fatal  cases,  fails  to  explain  that  larger 
class  of  non-fatal  cases  in  which  the  affection  is  confined  to  a 
small  group  of  muscles,  and  is  not  only  trifling  in  extent,  but 
of  limited  duration. 

In  some  of  the  recorded  cases  in  which  these  vegetations 
were  noticed,  there  was  no  audible  heart-murmur  during  life, 
nor  other  indication  of  valvular  disease,  which  could  hardly  be 
the  case  if  this  were  the  true  theory  of  causation.  It  should  be 
remembered,  too,  that  in  these  fatal  cases,  we  witness  the  ex- 
treme violence  of  the  choreic  manifestations,  accompanied  with 
delirium,  and  other  symptoms  denoting  central  ganglionic  dis- 
turbance— symptoms  always  absent  in  those  far  more  numerous 
cases  which,  from  their  comparative  mildness  and  brief  dura- 
tion, have  been  designated  chorea  minor.  The  clinical  differ- 
ences between  ordinary  chorea  and  the  acute  and  fatal  forms, 
are  of  themselves  suggestive  of  a  different  pathology,  and  the 
speedy  recovery  after  delivery  in  the  chorea  of  pregnancy,  or 
(as  in  several  cases  on  record),  after  expulsion  of  intestinal 
worms,  is  inconsistent  with  the  existence  of  embolism.  Avery 
important  consideration  in  this  connection,  is  the  remarkable 
limitation  of  chorea  to  the  period  of  childhood — the  period  be- 
tween infancy  and  puberty.  This  is  a  limitation,  as  stated  by 
Dr.  Broadbent,  "  if  not  without  parallel,  certainly  unequalled^ 


CHOREA   (ST.  VITUS'  DANCE).  665 

and  it  points  to  a  condition  of  nerve  centers  in  childhood 
which  specially  favors  the  occurrence  of  the  disease.  This 
condition  may  be  said  with  confidence  to  be  the  fact  that  child- 
hood is  the  period  of  special  activity  of  the  sensori-motor 
ganglia." 

There  seems  to  be  a  pretty  general  agreement  that  the  cor- 
pora striata  are  involved  in  the  disease,  but  there  are  many, 
among  whom  are  Dickinson,  Ross,  Meynert,  and  Hughhngs- 
Jackson,  who  doubt  whether  chorea  is  due  to  any  special 
disease  of  the  spinal  cord  or  other  part  of  the  nervous  system, 
but  think  that  it,  like  epilepsy,  is  due  to  a  disturbance  of  the 
whole  of  the  centers.  Dr.  Henry  P.  Stearns,  superintendent 
of  the  Hartford  Retreat,  says  that  the  primary  condition  is  one 
of  instability  of  fterve  function.  Such  a  change  has  occurred 
in  the  elemental  tissue  of  the  nerve  as  to  injure  its  power  of 
activity  so  far  as  it  is  under  the  control  of  the  will.  The  nerve 
has  been  stimulated  to  over-activity,  or  its  energy  impaired  by 
other  causes  arising  within  the  system  itself.  Dr.  Hughlings- 
Jackson  expresses  the  same  idea,  when  he  says  that  the  "  cen- 
ters are  diseased  when  half  educated,"  and  that  the  symptoms 
are  due  to  "  under  nutrition  "  of  the  tissues  affected. 

Symptoms  and  Course. — The  definition  of  Dr.  Sturges,  that 
"  Chorea  consists  in  an  exaggerated  fidgetiness,"  will  serve  to 
emphasize  the  fact  that  chorea  is  a  disease  of  varied  degree. 
In  slight  cases,  the  affection  may  amount  to  no  more  than  an 
involuntary  but  constant  winking  of  one  or  both  eyelids,  or  the 
twitching  of  one  corner  of  the  mouth.  But  in  severe  or  well- 
marked  cases,  the  child  lies  extended  in  bed,  making  all  sorts 
of  grimaces,  with  its  arms  stretched  out  on  the  countepane,  its 
fingers  pointing  in  all  directions  but  the  natural  one,  and  the 
forearms  and  arms  so  rotated  inwards  as  to  make  the  palms 
look  outwards.  In  mild  cases,  the  child  may  be  perfectly  quiet 
when  lying  down,  and  for  a  short  time  even  when  sitting  or 
standing,  if  not  conscious  of  being  observed  ;  but  when  walking 
or  while  under  examination,  there  will  be  various  fidgety  ac- 
tions, such  as  abrupt  flexion  of  the  fingers,  a  sudden  pronation 
of  the  forearm,  or  hitching  up  one  shoulder ;  or  there  is  a  shuf- 
fling of  a  foot  on  the  floor,  a  jerk  of  the  head  or  twitch  of  the 
mouth  or  eyelids.  If  the  patient  is  told  to  do  anything,  the 
movements  are  multiplied  in  the  muscles  employed  and  the 
actions  are  uncertain  and  erratic. 

An  object  will  be  picked  up  and  held,  but  the  hand  is  brought 
down  upon  it  hastily  and  after  various  random  excursions.  In 
the  severest  cases,  the  contortions,  grimaces  and  jerkings  are 
incessant. 

In  walking,  the  gait  is  slow,  shuffling,  and  uneven,  the  steps 


666  THE  DISEASES  OF  CHILDREN. 

of  unequal  length  and  time,  so  that  the  line  of  progress  is  devi- 
ating. In  these  severest  cases,  every  muscle  in  the  body  ap- 
pears to  be  thrown  in  turn  into  violent  contraction ;  the  face 
undergoes  the  most  grotesque  contortions,  the  eyes  roll  to  and 
fro,  the  teeth  are  snapped  or  ground  together,  the  whole  body 
writhes,  and  the  limbs  are  in  unceasing  motion.  The  patient 
cannot  put  a  cup  of  drink  to  his  mouth,  without  a  great  deal, 
of  management,  and  is  apt  to  spill  it  all  over  himself  or  his 
neighbor ;  mastication  becomes  diflficult  or  impossible,  and  the 
first  act  of  deglutition  is  impeded. 

There  is,  generally,  muscular  rest  during  sleep,  but  this  is 
by  no  means  constant.  In  many  cases,  there  is  great  difficulty 
in  falling  asleep,  owing  to  continuance  of  the  muscular  spasms, 
and  sleep,  w^hen  secured,  is  not  profound,  but  broken  by 
dreams  and  moans. 

On  awaking  in  the  morning,  there  is  at  first  muscular  rest,  but 
the  spasm  soon  commences,  especially  on  rising  and  attempt- 
ing to  dress. 

The  vocal  cords  and  muscles  of  the  larynx  may  be  affected, 
and  as  a  result,  there  is  a  quasi  aphonia,  so  that  the  speech  is 
husky  and  subdued.  In  other  cases,  the  voice  is  shrill  and 
squeaky.  Speech  is  nearly  always  modified.  The  incoordina- 
tion of  the  lips  and  tongue  make  it  difficult  to  articulate,  which 
is  quite  distressing  to  both  the  speaker  and  the  listener,  the 
words  being  "  snapped  "  and  cut  short.  In  some  cases,  speech 
is  quite  unintelligible.  The  patient  begins  a  sentence,  but  can- 
not finish  it  because  his  tongue  is  in  the  way ;  sometimes  he  is 
only  able  to  pronounce  one  syllable  at  a  time.  When  asked  to 
show  the  tongue,  it  is  thrust  out  suddenly  and  as  suddenly  re- 
tracted. This  sudden  protrusion  and  withdrawal  of  the  tongue, 
called  the  "choreic  thrust,"  is  almost  diagnostic  of  the  disor- 
der. In  the  majority  of  cases,  voluntary  motion  is  not  entirely 
abolished,  but  only  impeded  by  a  failure  of  the  coordinating 
power. 

Although  the  involuntary  movements  may  be  incessant,  the 
patient,  nevertheless,  succeeds  in  executing  voluntary  move- 
ments. It  is  true  that  he  performs  them  in  an  awkward, 
clumsy,  imperfect  and  roundabout  way ;  the  intended  move- 
ment is  commenced,  but  is  interrupted  by  twitchings  before  it 
can  be  executed.  The  patient  then  begins  to  maneuver  and 
succeeds  after  a  time  in  accomplishing  his  purpose ;  but  at 
other  times,  the  effect  of  exerting  the  will  seems  to  be  an  in- 
crease of  the  spasm,  which,  from  having  been  limited  to  the 
face  and  hands,  may  then  involve  the  whole  body.  Any  effort 
on  the  part  of  the  patient  to  subdue  the  spasm  and  to  keep 
his  face  and  limbs  quiet,  is  often  sufficient  to  increase  the  vio- 


CHOREA  (ST.  VITUS'  DANCE).  667 

lence  of  the  twitches.  It  is  to  be  remarked  that  even  in  ex- 
treme cases,  the  movements,  violent  as  they  may  be,  are  in 
some  degree  circumscribed ;  the  arms,  for  example,  are  not 
thrown  up  over  the  head,  nor  do  the  legs  go  to  the  full  extent 
of  their  range  of  motion.  The  tongue  is  rarely  bitten,  although 
the  lips  may  be. 

Chorea  is  generally  gradual  in  its  access,  even  in  those  cases 
which  eventually  become  severe.  It  is  very  commonly  one- 
sided for  a  time,  and  occasionally  so  throughout  (hemichorea). 
In  nearly  all  cases,  the  abnormal  movements  are  more  pro- 
nounced on  one  side  than  the  other,  and  this  is  generally  the  left. 
Mental  disturbances  are  rarely  absent,  and  become  more  devel- 
oped the  longer  the  disease  continues.  Most  patients  are  ex- 
tremely irritable  ;  good-natured  persons  become  passionate  ; 
the  peaceable  quarrelsome  ;  the  intelligent  appear  childish  and 
simple ;  the  countenance  becomes  dull  and  stupid  ;  there  is 
marked  inattention,  and  the  memory  is  impaired.  Some  pa- 
tients are  shy  and  timid  ;  all  are  more  or  less  silly.  In  some 
cases  this  amounts  to  imbecility.  These  symptoms  are  not  only 
observed  toward  the  end  of  a  prolonged  attack,  but  are  often 
present  at  an  early  period  of  the  complaint,  especially  when 
there  are  tendencies  to  or  complications  with  hysteria.  These 
aberrations  of  mind  are  not,  however,  likely  to  be  permanent, 
but  pass  away  as  recovery  in  general  takes  place. 

Complications.  —  We  have  already  spoken  of  the  fact  that 
rheumatism  is  by  some  good  authorities  regarded  as  a  factor  in 
producing  the  phenomena  of  chorea.  However  this  may  be, 
the  fact  stands  that  the  two  diseases  are  frequently  associated 
more  or  less  directly,  and  that  rheumatism  may  not  seldom  be 
regarded  in  the  light  of  at  least  a  complication.  Thus,  Goodhart 
has  compiled  a  list  of  one  hundred  and  forty-one  cases,  of  which 
number  thirty-nine  had  had  rheumatic  fever,  and  fifty  more  had 
a  history  of  rheumatism  in  some  of  their  near  relatives.  His 
conclusion  regarding  the  association  of  the  two  diseases  is  as 
follows :  "After  having  gone  carefully  into  the  question,  I  be- 
lieve some  thirty  per  cent,  of  families,  taken  indiscriminately, 
are  rheumatic,  while  for  chorea  the  percentage  is  about  sixty." 
There  is  in  some  cases  such  an  impairment  of  motor  power  in 
the  voluntary  muscles  as  to  amount  to  complete  paralysis. 
Chorea  sometimes  succeeds  hemiplegia  in  the  paralyzed  parts  ; 
more  rarely  chorea  deepens  into  paralysis.  Cases  again  are  met 
with,  in  which  with  facial  hemiplegia  there  is  chorea  of  the 
limbs  of  the  same  side. 

In  the  violent  and  fatal  forms  of  chorea  there  is  almost  always 
delirium.  Impairment  of  sensation  is  not  uncommon,  and 
hemi-anesthesia  is  almost  always  associated  with  hemichorea. 


668  THE  DISEASES  OF  CHILDREN. 

Hysteria,  more  or  less  pronounced,  is  quite  commonly  asso- 
ciated with  chorea.  We  have  already  spoken  of  the  frequency 
with  which  the  heart  is  involved  in  even  mild  cases  of  the  mal- 
ady. In  all  cases,  even  the  mildest,  the  heart  should  receive 
proper  attention. 

Prognosis. — There  is  nearly  always — always  in  cases  of  periph- 
eral origin — a  tendency  to  spontaneous  recovery. 

The  disease  is  rarely  fatal  in  children,  and  when  it  is  so,  the 
case  is  acute  and  violent  from  a  very  early  period  of  the  attack  ; 
and  it  is  rare  for  the  malady  to  run  its  usual  course,  and  then 
take  on  a  very  serious  character.  Relapses  are  very  common, 
and  the  oftener  they  occur  the  greater  danger  there  is  of  the 
disease  becoming  chronic  and  incurable.  The  average  dura- 
tion of  the  affection  is  stated  by  Broadbent  to  be  about  two 
months.  If  prolonged  beyond  the  third  month,  it  vmy  be  ex- 
ceedingly chronic,  and  go  on — now  better,  now  worse — for  one 
or  two  years.  When  associated  with  menstrual  disorders  in  girls, 
or  occurring  before  puberty,  the  prospects  for  recovery  are  bet- 
ter than  when  associated  with  acute  rheumatism,  or  after 
puberty. 

Diagnosis. — The  only  maladies  which  are  at  all  likely  to  be 
mistaken  for  chorea  are  paralysis  agitans — which  rarely  affects 
children — epilepsy,  locomotor  ataxia,  and  cerebral  and  spinal 
schlerosis.  A  brief  study  of  these  affections  will  suffice  to  differ- 
entiate them. 

Treatment. — The  treatment  of  chorea,  to  be  successful,  must 
take  cognizance  of  the  cause  and  the  nature  of  the  ailment  as 
affecting  the  individual  case  in  hand. 

As  we  have  seen,  a  great  variety  of  causes  may  operate  to 
produce,  in  a  given  case,  the  symptoms  of  chorea.  Each  case 
must  therefore  be  individualized,  and  the  treatment  adapted  to 
its  special  peculiarities.  Where  worms  are  suspected,  appropri- 
ate remedies  should  be  given  for  their  expulsion.  Girls  affected 
with  dysmenorrhea  or  menstrual  irregularities,  should  be  given 
remedies  suitable  for  regulating  the  menstrual  function.  In  all 
cases  of  chorea  the  nervous  system  is  more  or  less  unstrung, 
and  the  system  is  morbidly  impressionable.  For  this  reason 
the  surroundings  of  the  patient  should  be  made  favorable  to  rest 
of  body  and  mind. 

All  discussion  of  the  case  in  the  presence  of  the  unfortunate 
victim  should  be  avoided.  The  child  should  be  taken  out  of 
school  and  kept  out  until  cured. 

Light  exercise  of  a  rhythmical  character  is  very  beneficial.  I 
once  had  a  case  of  chorea  that  was  cured  by  the  use  of  roller 
skates.  Music  has  great  power  over  these  patients,  and  will 
often  have  a  most  soothing  and  beneficial  effect.     Dr.   Julia 


CHOREA   {ST.  VITUS'  DANCE).  669 

Holmes  Smith  relates  a  case  of  a  ballet  dancer,  who  had  perfect 
control  over  her  limbs  when  engaged  in  dancing,  but  who,  after 
retiring  from  the  stage,  would  be  seized  with  the  most  horrible 
contortions.  As  both  plethoric  and  anemic  children  are  subject 
to  chorea,  the  diet  should  be  adapted  to  the  special  nutritive 
needs  of  the  individual.  Judicious  feeding  will  be  often  found 
a  powerful  adjunct  to  medicinal  treatment. 

In  our  own  experience  we  have  found  electricity  to  be  a 
remedy  par  excellence.  We  have  always  used  the  Faradic  cur- 
rent, giving  it  as  strong  as  could  be  borne  without  discomfort. 
Our  method  of  applying  it  has  been  to  place  one  pole  (indis- 
criminately), over  the  solar  plexus,  and  slowly  pass  the  other 
up  and  down  the  spine,  continuing  the  application  for  from 
seven  to  ten  minutes  daily. 

Massage  is  another  measure  which  has  seemed  to  be  very 
helpful  in  many  severe  cases. 

Among  the  drugs  which  have  been  successfully  used  in  the 
treatment  of  chorea,  arse?iic  stands  preeminent.  The  patho- 
genesis of  arsenic  abounds  in  symptoms  simulating  all  forms  of 
nervous  diseases. 

Dr.  Hammond  and  other  authorities  of  the  Old  School  give 
the  drug  in  the  form  of  Fowler's  Solution,  administering  it,  by 
preference,  hypodermatically.  It  may  be  administered  in  this 
manner  to  a  child  in  doses  of  from  two  to  five  drops,  diluted 
with  an  equal  quantity  of  glycerin.  In  using  the  hypoderma- 
tic syringe,  Hammond  says :  "  The  safest  location  is  on  the 
front  of  the  forearm,  about  midway  between  the  wrist  and 
elbow.  Here  the  skin  is  loose  and  can  be  easily  lifted  up  by 
the  thumb  and  finger  from  the  tissue  below.  The  arsenic 
should  be  deposited  just  under  the  skin  in  the  cellular  tissue, 
and  not  in  the  substance  of  the  muscle  or  skin.  The  point  of 
the  syringe  should  be  carried  just  through  the  skin  and  then 
for  half  an  inch  parallel  to  the  face  of  the  arm,  and  the  injec- 
tion made  slowly." 

In  cases  complicated  with  paralysis,  strychnia  affords  an  ad- 
mirable remedy.  Dr.  Hale  says  that  in  these  cases,  he  has 
found  the  arsenite  of  strychnia  2x  of  decided  value.  He  also 
gives  the  following  indications  for  cuprum,  which  he  regards 
highly  in  certain  cases :  '•  The  choreic  movements  are  charac- 
teristic. They  appear  to  start  in  the  fingers  and  toes  and 
spread  to  the  muscles  of  the  limbs.  The  patients  are  better 
when  lying  down,  and  when  asleep,  although  the  sleep  is  not 
entirely  free  from  choreic  movements.  The  muscles  of  the 
throat  are  affected,  causing  dread  of  suffocation,  and  difficult 
deglutition.  As  taught  by  Rademacher,  under  certain  circum- 
stances, copper  appears  to  enrich  the  blood  like  iron.     If  your 


670  THE  DISEASES  OF  CHILDREN. 

cases  are  chlorotic,  it  is  an  additional  indication  for  copper. 
If  cuprum  fails,  try  the  arsenite  of  copper,  which,  in  my  hands, 
has  cured  two  cases.  Tablets  of  the  ix  or  2x;  one  after  meals, 
and  at  bedtime."  This  same  high  authority  thus  speaks  of 
cimicifuga:  "  It  is  useful  both  in  '  fright  chorea '  and  in  many 
cases  of  chorea  appearing  just  before  or  at  puberty  in  girls. 
Cimicifuga,  given  freely,  will  bring  on  the  menses,  after  which 
the  chorea  will  improve.  It  will  cure  chorea  in  older  girls 
when  it  appears  only  before  and  during  menses.  The  active 
principle,  cunicifiiginy  sometimes  called  '  macrotin,'  is  quite  as 
efificient  and  more  convenient,  for  a  tablet  of  the  ix,  containing 
one-tenth  of  a  grain,  is  equal  to  five  drops  of  the  tincture." 

Dr.  C.  L.  Gregory,  and  many  other  homeopathic  physicians, 
have  had  good  success  with  gelsemiuni,  especially  in  cases 
where  the  heart's  action  is  weakened.  Special  stress  is  laid  on 
the  importance  of  administering  a  good  preparation  of  the  green 
or  freshly  dried  root. 

Veratrum  viride  is  recommended  highly  in  cases  of  chorea, 
affecting  robust  girls,  having  violent  attacks,  the  spasmodic 
movements  var>'ing  on  tetanus  and  opisthotonos.  The  heart's 
action  is  very  violent,  and  perhaps  spasmodic.  (Dose  of  the 
tincture,  one  to  five  drops  every  three  hours.) 

In  a  discussion  before  the  American  Institute  of  Homeop- 
athy some  years  ago.  Dr.  T.  F.  Allen  stated  that  he  valued 
cicuta  very  highly  in  chorea,  although  it  was  a  remedy  not 
often  used  by  others.     He  gave  it  in  the  sixth  dilution. 

At  the  same  meeting,  Dr.  Kershaw  spoke  of  having  had 
great  success  with  valerianate  of  zinc,  which  he  administered 
in  the  first  to  the  third  trituration.  He  mentioned  several 
cases  of  severe  type  which  had  yielded  to  this  remedy  when 
others  had  failed. 

Tarantula  is  a  remedy  which  has  many  advocates,  especially 
in  cases  that  tend  to  recur  or  become  chronic. 

Nux  vomica. — This  remedy  is  often  required,  and  is  indicated 
in  those  cases  when  the  child  complains  of  vague  flying  pains 
about  the  legs  and  chest ;  also  a  twitching  of  the  jaws  and  up- 
per extremities.  Other  symptoms  are  a  sense  of  numbness  in 
the  affected  muscles ;  unsteady  gait ;  the  feet  drag ;  move- 
ments renewed  by  the  least  touch,  but  lessened  by  steady  pres- 
sure; impaired  appetite ;  constipation,  despondency ;  all  the 
symptoms  worse  in  the  early  hours  of  the  morning. 

Ignatia  is  useful  when  the  left  side  is  mainly  affected;  when 
the  convulsive  twitchings  are  brought  on  by  fright  or  grief ;  are 
worse  after  eating;  sighing  and  sobbing,  and  disposition  to  be 
alone  are  also  characteristic. 

Calcarea  carb.  is  indicated  in  chorea  connected  with  denti- 


CHOREA  {ST.  VITUS'  DANCE).  671 

tion,  or  in  leuco-phlegmatic  patients ;  also  when  the  disorder 
is  brought  on  from  fright  or  onanism ;  there  are  the  usual 
twitching  of  the  muscles,  trembling,  and  great  weariness. 

Hyoscyamiis  and  stramonium  are  favorite  and  often-indicated 
remedies.  In  the  hyoscyamus  case  the  movements  of  the  head 
are  from  side  to  side  ;  the  arms  thrown  about,  the  gait  totter- 
ing, and  the  patient  is  talkative  and  easily  excited  to  laughter. 
The  symptoms  calling  for  stramonium  are  exceedingly  charac- 
teristic ;  the  convulsive  movements  have  the  feature  of  affect- 
ing the  parts  of  the  body  crosswise,  as,  for  instance,  the  left 
arm  and  the  right  leg,  while  the  other  limbs  are  unaffected  ;  or 
the  muscles  of  the  head  and  neck  are  violently  agitated ;  or 
the  spasms  may  involve  the  whole  body,  compelling  the  per- 
formance of  the  most  grotesque  leaps,  motions,  and  gestures ; 
is  full  of  fears  ;  handles  the  genital  organs ;  weeps  and  laughs 
alternately. 

Speaking  from  our  own  experience,  the  remedy  which  has 
seemed  to  be  more  generally  efficacious  than  any  other  is  the 
mono-bromid  of  camphor  in  the  2x  or  3X  trituration.  We  recall 
three  cases  in  which  it  was  the  only  remedy  given,  and  in  which 
the  improvement  was  immediate  and  permanent. 

In  delicate  and  anemic  girls,  every  means  should  be  em- 
ployed to  enrich  the  blood  and  improve  the  general  tone  of 
the  system.  Cod-liver  oil  and  some  preparation  of  iron  are  of 
unquestionable  value  in  such  cases.  There  is  a  new  prepara- 
tion of  cod-liver  oil  which  is  quite  free  from  the  objectionable 
taste  of  the  crude  oil,  and  of  the  various  emulsions,  and  which 
we  have  found  very  beneficial — "  Steam's  Wine  of  Cod-Liver 
Oil." 

This  preparation  can  be  given  to  any  one  regardless  of  their 
antipathies,  as  the  taste  and  smell  of  the  oil  are  perfectly  dis- 
guised. 

The  moral  treatment  of  these  cases  must  not  be  forgotten. 
They  must  be  encouraged  and  cheered ;  over-taxation  of  mind 
and  body  must  be  interdicted  ;  good  food  and  fresh  air,  with 
plenty  of  rest,  are  essential  to  their  recovery.  Dr.  Edward 
Blake,  of  London,  regards  stammering  as  a  local  chorea,  and 
reports  several  cures  effected  by  means  of  labial  gymnastics, 
electricity,  and  the  properly  affiliated  homeopathic  remedy. 


CHAPTER  IV. 

INFANTILE  TETANUS  (TRISMUS  NASCENTIUM  ;   LOCKJAW). 

Definition. — Infantile  tetanus  is  a  rare  but  very  fatal  form  of 
eclampsia  occurring  occasionally  during  the  first  two  weeks  of 
life,  and  characterized  by  more  or  less  general  tonic  contraction 
of  the  voluntary  muscles  ;  the  spasm  beginning,  as  a  rule,  in 
the  muscles  of  mastication,  from  which  it  extends  to  those  of 
the  trunk  and  limbs,  with  irregularly  recurring  exacerbations  of 
short  duration. 

Causes. — The  causes  which  have  been  assigned  from  time  to 
time  for  the  production  of  infantile  tetanus  are  very  numerous  ; 
the  latest  theory  being  that  it  is  propagated  and  disseminated  by 
means  of  its  own  peculiar  bacillus,  and  that  it  is  both  contagious 
and  infectious.  As  this  view  of  the  subject  has  as  much  ground 
to  support  it  as  any  which  has  preceded  it,  it  will  doubtless  be 
rigidly  maintained  until  another  and  more  plausible  theory 
supplants  it.  It  is  a  very  rare  disease  among  the  upper  classes 
and  the  well-to-do,  and,  in  our  northern  climate,  is  exceedingly 
rare  outside  the  larger  cities.  It  is  more  prevalent  in  the 
extreme  south,  and  more  common  among  the  blacks  than 
whites.  Many  physicians  having  a  long  and  extensive  practice 
have  probably  never  seen  a  case  of  it ;  and  yet,  in  some  coun- 
tries, it  figures  quite  formidably  in  the  record  of  mortuary 
statistics.  Dr.  J.  Lewis  Smith  says  that  in  New  York  City  it  is 
more  common  than  tetanus  at  any  other  age,  or,  indeed,  in  all 
other  ages,  "  since  the  mortuary  statistics  of  this  city  exhibit 
a  larger  number  of  deaths  from  this  disease  in  the  first  year  of 
life  than  subsequently."  For  the  year  1892  the  health  depart- 
ment reports  of  Chicago  show  twenty-five  deaths  from  infantile 
tetanus  to  forty  deaths  from  tetanus  among  adults.  Dr.  Smith 
confirms  the  experience  of  most  other  observers  who  have  stud- 
ied the  affection,  that  tetanus  is  nearly,  if  not  always,  found 
among  the  filthy,  ill-fed  and  depraved  residents  of  the  slums. 
It  may  be  said  to  be  always  and  everywhere  associated  with 
dirt  and  ignorance.  Dr.  Marion  Sims  and  others  have  endeav- 
ored to  prove  that  one  of  the  most  common  causes  of  trismus 
was  displacement  of  the  occipital  bone  from  over-riding;  others 
have  attached  great  importance  to  the  bad  condition  of  the 
(672) 


INFANTILE   TETANUS.  673 

umbilical  cord,  which  in  several  instances  has  been  found  sup- 
purating, or  in  a  state  of  inflammation.  Without  entering  into 
a  discussion  of  the  vexed  question,  it  can  be  safely  stated  that 
the  cause  is  not  always  the  same,  and  that  among  the  most  com- 
mon etiological  factors  in  its  production  are  irritation  and  in- 
flammation of  the  umbilical  cord,  injuries  to  the  head  or  other 
portions  of  the  body  during  birth,  circumcision,  cold  and 
dampness. 

Any  or  all  of  these  agencies  are  capable  of  producing,  in  a 
new-born  infant,  other  things  being  favorable,  that  train  of  phe- 
nomena which  is  called  tetanus. 

Symptoms. — Tetanus  neonatorum  comes  on  usually  between 
the  third  and  eighth  day  after  birth,  but  occasionally  not  until 
some  days  later.  Dr.  J.  L.  Smith  has  tabulated  forty  cases,  in 
which  the  youngest  case  was  under  two  days  old,  the  oldest 
twelve  days,  and  nine  cases  were  three  days  old.  Niemeyer 
says — but  this  is  undoubtedly  an  error — that  it  never  occurs 
except  between  the  first  and  fifth  day  after  the  fall  of  ihe  navel 
string.  Restlessness  is  generally  the  first  noticeable  symptom 
of  an  attack ;  the  child  cries  out  in  its  sleep  and  seems  greatly 
distressed. 

It  next  refuses  to  be  pacified  with  the  breast,  or  becomes  in- 
capable of  taking  it.  The  nipple,  if  seized,  cannot  be  retained, 
and  the  milk  is  regurgitated  or  dribbles  out  of  the  mouth, 
owing  to  the  difficulty  of  swallowing.  On  attempting  to  insert 
the  finger  into  the  mouth  of  the  patient,  we  find  that  the  jaws, 
though  not  absolutely  closed,  are  more  or  less  fixed.  There  is 
rigidity  of  the  masseters,  and  the  disease  gradually  extends  to 
the  other  voluntary  muscles,  so  that  in  the  course  of  a  few 
hours  the  muscles  of  the  limbs,  as  well  as  of  the  trunk,  are  in- 
volved. The  rigidity  of  the  muscles  is  progressive,  and  when 
it  has  reached  its  maximum,  the  jaws  are  fixed  almost  immov- 
ably, often  with  a  little  interspace  between  them,  through  which 
the  tongue  presses,  and  in  which  frothy  saliva  collects.  Stiffen- 
ing of  the  cervical  muscles  draws  the  head  backward  and  holds 
it  there;  the  forearms  are  flexed  ;  the  thumbs  are  drawn  across 
the  palms  of  the  hands  and  are  firmly  clenched  by  the  fingers  ; 
the  great  toes  are  adducted,  and  the  other  toes  flexed.  Occa- 
sionally opisthotonos  results  from  the  extreme  contraction  of 
the  dorsal  and  posterior  cervical  muscles. 

Frequent  exacerbations  occur  in  the  muscular  contractions, 
sometimes  without  apparent  cause,  and  sometimes  produced 
by  anything  which  excites  or  disturbs  the  child.  Handling  and 
attempts  at  feeding  provoke  renewed  paroxysms.  During  the 
paroxysms  the  eyelids  are  tightly  compressed,  as  well  as  the 
lips  ;  the  forehead  and  cheeks  are  thrown  into  wrinkles,  and  the 
D.  C— 43 


674  THE  DISEASES  OF  CHILDREN. 

physiognomy  is  indicative  of  great  suffering.  Breathing  is 
much  impeded,  and  in  some  cases  suspended,  so  that  the  child 
dies  of  suffocation.  In  fatal  cases,  the  paroxysms  occur  more 
and  more  frequently  until  the  period  of  collapse.  It  is  usually 
difficult,  if  not  impossible,  to  ascertain  the  condition  of  the 
pupils,  owing  to  the  firm  compression  of  the  eyelids. 

In  some  cases,  strabismus  has  been  noticed.  During  the 
stage  of  collapse  the  pupils  are  usually  contracted.  Death 
usually  supervenes  from  exhaustion  in  from  a  few  hours  to  two 
or  three  days. 

The  mortality  is  very  large.  Wallace  reports  thirty-four  cases 
with  twenty-nine  deaths ;  and  J.  Lewis  Smith  forty  cases,  with 
thirty-two  deaths.  In  some  epidemics,  and  in  certain  localities^ 
all  the  cases  are  fatal. 

Treatment. — Nearly  everything  in  the  materia  medica  of  all 
schools  of  medical  practice  has  been  tried  in  these  cases ;  but 
with  very  unsatisfactory  results.  Heroic  treatment  by  means 
of  ice  bags,  copious  sweatings  and  anesthetics,  which  has  been 
resorted  to  in  the  tetanic  convulsions  affecting  adults,  is,  of 
course,  not  to  be  thought  of  in  treating  the  new-born. 

The  difficulties  of  treatment  are  enhanced  by  the  fact  that 
the  patient  is  in  most  instances  unable  to  swallow,  so  that  the 
administration  of  medicine  by  the  mouth  is  impossible.  The 
hypodermatic  syringe,  however,  enables  us  to  use  such  drugs 
as  can  be  employed  in  a  fluid  and  concentrated  form.  The  drugs 
which  seem  to  have  been  most  useful  are  strychnia,  gelsemium, 
conium,  cicuta,  and  passiflora  incarnata.  The  latter  is  highly 
lauded  by  Drs.  Lindsay  and  Phares,  of  Louisiana,  but  it  has  to 
be  given  in  large  doses — a  teaspoonful  at  frequent  intervals.  In 
administering  the  remedy,  care  must  be  taken  to  procure  a 
fresh  preparation,  as  it  is  subject  to  deterioration  if  kept  long. 

The  main  dependence  must  be  in  sustaining  the  strength  of 
the  patient,  who  is  not  only  menaced  by  suffocation,  but  star- 
vation. Stimulants  and  nourishment  must  be  given  by  forced 
feeding,  or  "  gavage,"  as  described  on  page  6i,  the  rubber  tube 
being  inserted  through  the  nose,  if  the  mouth  is  not  available. 
The  hot  bath,  or  even  the  hot  pack,  may  prove  serviceable. 


CHAPTER  V. 

PARALYSIS. 

This  symptom  may  occur  in  children  from  the  same  causes 
as  in  adults.  If  the  physician  will  bear  in  mind  the  fact  that 
paralysis  is  not  a  disease,  but  simply  a  symptom  of  disease,  and 
that  a  diagnosis  is  not  made  until  the  disease  or  lesion,  causing 
this  symptom,  is  discovered,  he  will  save  many  failures. 

Cerebral  Paralysis. — Cerebral  paralysis  is  a  loss  of  vol- 
untary motion  from  some  pathological  condition  within  the 
cranium  ;  it  may  be  congenital  or  appear  at  any  age. 

There  are  recorded  a  large  number  of  cases  of  cerebral  hem- 
orrhage occurring  at  birth,  especially  in  conjunction  with  pro- 
tracted or  instrumental  labor.  In  these  cases  there  is  usually 
rapid  softening  and  breaking  down  of  cerebral  tissue,  not  infre- 
quently to  an  extent  which  leaves  quite  large  cavities  in  the 
brain  ;  they  are  much  more  common  in  the  motor  tract,  than 
in  other  parts. 

Symptoms. — At  the  onset  of  any  cerebral  paralysis,  there  are 
likely  to  be  present  concomitant,  symptoms,  due  to  shock  and 
general  molecular  change,  convulsions,  fever,  delirium,  coma  or 
emesis.  Bear  in  mind  that  a  child  is  much  more  susceptible 
to  any  impressions  on  nerve  structure  than  an  adult.  The 
location  and  extent  of  the  convulsion  at  the  onset  are  of  prac- 
tically no  assistance  in  localization ;  they  may  be  confined  to 
one  member,  to  one  side  of  the  body,  or  be  general,  no  matter 
where  the  lesion  is  located.  Convulsions  recurring  later  may 
be  of  the  greatest  importance  in  localization.  Febrile  disturb- 
ance is  usually  of  a  very  mild  nature,  the  temperature  rarely 
going  above  ioi°  Fahr. 

Delirium  is  often  lacking,  and  when  present  is  usually  mild. 
Somnolence  is  usually  present,  and  not  infrequently  pronounced 
coma.  Emesis,  according  to  my  experience,  is  quite  common, 
but  not  of  a  severe  character. 

The  direct  symptoms,  that  is,  those  dependent,  not  on  shock, 
but  the  direct  result  of  the  lesion,  sometimes  termed  localizing 
symptoms,  are  paralysis,  contractures,  exaggerated  tendon 
reflexes,  mental  alienation  or  impairment,  muscular  wasting, 
and  impairment  of  speech  and  hearing. 

(675) 


C76  THE  DISEASES  OF  CHILDREN. 

The  direct  symptom,  paralysis,  may  be  classed  under  the 
four  groups,  hemiplegia,  double  or  bilateral  hemiplegia,  or  di- 
plegia ;  paraplegia  and  monoplegia.  Hemiplegia  is  most  com- 
mon previous  to  the  third  year;  if  the  face  is  involved,  which  is 
not  very  common,  it  is  confined  to  the  parts  below  the  eye. 
Diplegia  is  usually  congenital,  and  the  result  of  injury  to  the 
brain  during  labor  or  to  fetal  troubles.  Paraplegia  is  most  fre- 
quently congenital,  but  occasionally  appears  in  early  infancy. 
Monoplegia  is  much  more  frequent  after  the  third  year. 

Contracture  of  the  paralyzed  muscles  is  almost  always  pres- 
ent ;  not  a  rigid,  but  a  pliable  contracture.  Light,  steady,  gentle 
effort  by  an  attendant  will  overcome  the  contracture,  but  the 
limb  very  soon  returns  to  its  original  position.  The  joints  are 
usually  very  pliable,  so  that  the  limb  can  be  readily  moved  in 
any  direction  by  an  attendant. 

The  tendon  reflexes  are  usually  slightly  exaggerated. 

The  mental  condition  may  be  anything,  from  acute  mania  to 
a  slight  aberration,  or  from  a  simple  arrest  of  intellection  to 
absolute  idiocy. 

Muscle  wasting  is  not  very  pronounced,  but  is  usually  pres- 
ent in  some  degree.  It  is  not  an  atrophy,  but  a  lack  of  devel- 
opment as  a  result  of  non-use. 

Disorders  of  speech  of  every  shade  occur  and  are  very  com- 
mon. 

Derangements  of  hearing  are  not  very  common,  but  occasion- 
ally occur. 

The  electrical  reactions  are  nearly  normal. 

The  affected  limb  is  apt  to  have  a  slightly  lower  temperature 
and  a  poor  circulation. 

Spastic  chorea,  athetosis,  and  post-hemiplegic  tremor  occa- 
sionally occur. 

Recurrent  epileptiform  convulsions  occur  in  a  large  number 
of  the  cases.  They  may  be  either  general,  which  is  most  fre- 
quent, or  they  may  be  well-defined  localized  convulsions. 

Diagnosis. — In  making  a  diagnosis,  the  history  from  the  on- 
set should  be  very  carefully  taken  in  minute  details ;  not  infre- 
quently you  will  find  your  only  clue  to  a  correct  diagnosis  in 
the  onset  and  chronology  of  the  case. 

In  cerebro-spinal  meningitis,  sporadic  or  epidemic,  the  paral- 
ysis is  very  rarely  bilateral.  There  is  a  marked  tendency  to 
somnolence  or  coma ;  there  is  a  high  temperature,  almost  inva- 
riably marked  retraction  of  the  head,  and  general  indications 
of  severe  illness,  such  as  you  will  very  rarely  find  in  the  onset 
of  a  cerebral  paralysis. 

In  suppurative  meningitis,  there  are  marked  remissions  of 
symptoms,  a  fluctuating  temperature  and  pulse,  chills,  and  the 


PARALYSIS.  677 

general  accompaniments  of  sepsis,  and  there  will  be  a  discharge 
of  pus  from  lung,  ear,  orbit  or  nasal  cavity. 

In  anterior  polyomyelitis  the  contraction  of  muscles,  except- 
ing in  long-standing  cases,  is  absent ;  the  tendon  reflex  is  ab- 
sent, electrical  reaction  of  the  paralyzed  muscle  is  altered,  and 
there  is  true  muscular  atrophy  of  a  part  or  all  of  the  paralyzed 
muscles. 

In  transverse  myelitis  there  are  rectal  and  vesical  compli- 
cations. 

Prognosis. — The  gravity  of  the  condition  depends  on  the 
extent  of  the  cerebral  lesion  as  shown  by  the  mental  condition, 
the  extent  and  character  of  the  paralysis,  the  contractures,  and 
the  condition  of  the  reflexes. 

Multiple  Cerebro-Spinal  Sclerosis. — Synonyms:  Dis- 
seminated  Sclerosis,  Insular  Sclerosis,  Focal  Sclerosis,  Charcot's 
Sclerosis.  The  sclerotic  patches  may  be  in  the  brain,  in  the 
spinal  cord,  or,  as  is  most  frequently  the  case,  in  both.  The 
condition  is  very  uncommon  in  children,  but  occurs  with  suffi- 
cient frequency  to  warrant  a  description. 

Symptoms. — According  to  Charcot,  there  are  two  modes  of 
onset  :  one  is  sudden ;  the  tremor,  weakness  and  ataxy  date 
from  convulsion  or  an  apoplectiform  seizure.  In  the  other 
form  the  onset  is  slow  and  insidious ;  vertigo,  headache,  vague 
muscular  weakness,  with  incoordination  and  tremor,  are  the 
symptoms  first  noted.  In  both  modes  of  onset,  occular  symp- 
toms, such  as  third  and  sixth  nerve  paresis,  optic  nerve  atrophy, 
and  nystagmus,  defects  of  articular  speech,  mental  weakness, 
sensory  disturbances,  and  contractures  occur  to  complete  the 
diagnosis. 

In  childhood,  the  first  form,  or  the  sudden  onset,  is  much 
the  more  common.  Tremor  is  always  present  in  cases  in  chil- 
dren. It  may  be  general,  even  involving  the  head,  bilateral  or 
unilateral.  It  is  a  pronounced,  coarse  tremor,  and  is  intensified 
by  voluntary  muscular  exertion.  Ataxy  of  various  degrees  and 
forms  will  be  observed  in  the  progress  of  every  case.  It  may 
be  in  the  upper  extremities,  shown  by  an  inability  to  carry 
food  to  the  mouth,  or  an  inability  to  control  the  hand  in  writ- 
ing or  other  movements  requiring  fine  coordination,  and  is  not 
due  to  tremor  or  paralysis.  The  gait  may  be  staggering  or 
like  that  in  posterior  spinal  sclerosis,  or  there  may  be  a  certain 
rigidity  of  gait,  combined  with  an  inability  to  place  the  foot 
where  it  is  desired,  except  by  the  aid  of  vision. 

Very  early  there  is  likely  to  be  transient  strabismus,  dilata- 
tion of  the  pupils,  drooping  of  the  lids ;  later,  in  many  cases, 
there  will  be  found  optic  nerve  atrophy.     Nystagmus  occurs  in 


678  THE  DISEASES  OF  CHILDREN. 

about  half  of  the  cases.  It  may  be  noticed  only  on  horizontal 
or  lateral  movements  of  the  eye,  under  excitement,  at  irregular 
intervals,  or  constantly. 

Probably  the  most  common  disorder  of  speech  is  a  slow 
articulation,  each  syllable  and  word  being  separate,  a  true 
scanning  speech  ;  there  may  be  more  or  less  marked  tremor  in 
speaking,  and  any  grade  of  indistinctness,  from  a  simple,  thick 
articulation  to  absolute  unintelligibility. 

The  intellect  is  usually  much  impaired  and  not  infrequently 
there  is  absolute  dementia. 

Very  early  in  the  case  there  is  usually  a  peculiarly  sharp, 
circumscribed,  neuralgic  headache ;  most  frequently  frontal. 
More  or  less  headache  is  often  a  very  persistent  symptom. 
Vertigo  is  quite  common. 

Early  in  the  attack,  paralysis  of  the  third  or  sixth  nerve,  or 
of  both,  is  quite  common.  As  the  case  progresses,  the  facial 
muscles,  and  those  of  the  tongue,  lips,  and  pharynx  are  occa- 
sionally paralyzed.  The  extremities  are  usually  paralyzed  in 
the  later  stages. 

The  superficial  reflexes  are  not  usually  affected,  except  in  the 
late  stage  of  the  disease.  The  knee  jerk  is  apt  to  be  exaggerated 
early.  In  a  few  cases  where  the  posterior  column  is  especially 
involved,  the  knee  jerk  may  be  diminished  or  absent. 

Causes. — In  regard  to  the  causes  of  this  disease,  in  by  far  the 
larger  number,  none  can  be  determined.  There  is  no  doubt 
that  heredity  is  an  important  element  in  starting  the  child  with 
a  predisposition  to  nerve  trouble.  It  has  followed  acute  infec- 
tious diseases  closely  enough  to  be  reasonably  attributed  to 
them.  Injury  to  brain  or  spine  may  be  a  direct  cause.  Sudden 
and  severe  emotional  shock  has  seemed  to  be  the  direct  cause 
in  some  instances. 

Diagnosis. — In  children  there  will  never  be  any  difficulty  in 
differentiating,  except  between  it  and  Friedreich's  ataxy.  In 
this  disease  the  tremor  is  not  nearly  so  common,  and  when 
present  is  never  confined  to  efforts  at  voluntary  motion,  and  is 
more  like  chorea.  The  nystagmus  is  only  noticed  when  the 
eyes  are  directed  to  some  object.  The  knee  jerk  is  almost  in- 
variably absent  or  very  much  reduced  ;  the  intellect  is  rarely 
affected. 

Prognosis. — This  disease  may  be  classed  among  the  incurables. 
The  physician  sometimes,  and  the  friends  usually,  will  be  much 
encouraged  from  time  to  time,  because  of  marked  temporary 
remissions  in  the  symptoms,  and  on  account  of  days  or  weeks 
passing  without  any  noticeable  advance.  It  should  not  be  for- 
gotten that  such  remissions  and  times  when  there  is  no  advance- 
ment belong  to  the  regular  course  of  the  disease.     A  few  cases 


CEREBRAL  HEMORRHAGE.  679 

have  seemed  to  be  arrested  for  a  term  of  years,  whether  due  to 
treatment  I  cannot  say.  Death  will  almost  invariably  result 
directly  from  inability  to  swallow  on  account  of  bulbar  paresis, 
from  lung  complications  on  account  of  enervation  of  these  or- 
gans, to  inanition,  from  the  loss  of  trophism,  or  to  some  inter- 
current trouble. 

Treatment. — As  to  treatment,  if  a  well-defined  heredity  or 
acquired  syphilitic  taint  be  present  potassium  iodide  should  al- 
ways be  exhibited.  It  is  my  habit  to  give,  if  the  patient  is  un- 
der fourteen  years  of  age,  from  three  to  five-grain  doses  in  four 
drachms  of  water  four  times  a  day.  In  all  cases  where  no 
syphilitic  taint  can  be  clearly  determined,  the  careful  study  for 
the  indicated  remedy,  and  extending  through  the  entire  list, 
is  the  best  that  you  can  do.  My  own  great  reliance,  and  the 
treatment  I  use  in  every  case,  even  in  a  very  small  child,  is 
nerve  vibration. 


CEREBRAL   HEMORRHAGE,   THROMBUS   AND   EMBOLISM. 

The  symptoms  and  results  of  these  three  conditions  are  so 
similar  that  they  can  be  better  considered  together  than  sepa- 
rate ;  the  differences  essential  to  correct  diagnosis  and  for  treat- 
ment must  be  carefully  noted.  They  are  not  as  frequent  in 
children  as  in  adults,  but  are  very  much  more  frequent  than  was 
supposed  a  few  years  ago. 

Cerebral  Hemorrhage  is  an  extravasation  of  blood  of 
any  amount,  from  rupture  of  one  or  more  blood-vessels  within 
the  cranium. 

Causes. — It  may  be  caused  at  birth  by  a  long,  protracted 
labor,  or  by  the  use  of  forceps,  by  traumatism  at  any  time  sub- 
sequent to  birth,  by  diseased  blood-vessels;  miliary  tubercles 
are  found  in  a  good  many  cases.  Dr.  Sachs  has  called  particu- 
lar attention  to  a  degeneration  of  blood-vessels  apparently  pe- 
culiar to  young  people.  Anything  that  causes  a  very  marked 
increase  of  the  blood  pressure,  either  general  or  intracranial, 
such  as  paroxysms  of  whooping  cough,  straining  at  stool,  sud- 
den and  violent  exercise,  sudden  and  violent  emotion,  fright, 
or  convulsions  may  be  followed  immediately  by  cerebral  hem- 
orrhage. It  may  be  looked  for  as  a  possible  complication  in 
typhoid  fever,  scarlet  fever,  small-pox,  diphtheria,  rheumatism 
and  acute  miliary  tuberculosis.  In  these  cases  it  may  follow 
immediately  an  initial  convulsion,  or  as  is  more  frequent,  appear 
in  the  latest  stage  of  the  disease.  Hereditary  or  acquired  syph- 
ilis may  be  a  cause. 


680  THE  DISEASES  OF  CHILDREN. 

Thrombosis  is  an  occlusion  of  one  or  more  of  the  cerebral 
vessels  from  abnormal  conditions  in  the  vessels,  and  the  for- 
mation of  a  clot  within  the  vessel  or  vessels  at  the  point  of 
trouble. 

Causes. — This  may  be  caused  by  hereditary  or  acquired 
syphilis,  tubercular  conditions,  or  any  disease  producing  degen- 
eration of  the  blood-vessels.  From  my  own  experience  and 
reading.  I  conclude  that  this  disease  is  exceedingly  rare  under 
twenty-five  years  of  age. 

Embolism  is  a  plugging  of  a  cerebral  blood-vessel  by  clot  or 
other  substance  carried  to  the  point  of  trouble,  by  the  blood 
current,  from  some  other  part  of  the  body. 

Causes. — Such  diseases  as  bronchitis,  pneumonia,  diphtheria,, 
small-pox,  scarlet  fever,  measles  and  rheumatism — in  short,  any 
disease  likely  to  cause  fungus  formation  on  the  valves  or 
thrombus  in  the  pulmonary  veins — may  be  fruitful  sources  of 
this  condition.  Hemorrhoids,  or  wounds  in  which  a  clot  may 
form,  partly  within  a  blood-vessel,  may  have  a  portion  of  the 
clot  washed  into  the  blood  current  and  carried  by  it  to  a  cere- 
bral vessel.  Embolism  is  probably  more  frequent  in  young  chil- 
dren than  hemorrhage,  and  very  much  more  so  than  thrombus. 

Symptoms. — If  either  of  these  lesions  occur  at  birth,  it  will 
be  difficult  to  establish  evidence  of  life  or  regular  respiration. 
Nothing  further  abnormal  may  be  noticed  for  days  or  even 
weeks.  A  hemiplegia  or  paraplegia,  of  either  the  arms  or  the 
legs,  or  a  monoplegia,  may  appear  very  soon,  or  may  not  be 
noticed  for  some  weeks.  Contractures  will  appear  soon  after 
the  paralysis.  It  is  very  rare  for  any  convulsive  seizures  to 
appear  during  the  first  few  months. 

If  the  lesion  occurs  subsequent  to  birth,  it  may  be  during- 
apparent  perfect  health,  or  in  the  course  of  the  diseases 
mentioned  as  causes.  In  nearly  every  case,  there  will  be  loss 
of  consciousness,  it  may  be  a  simple  somnolence,  or  an  absolute 
coma.  There  may  or  may  not  be  a  convulsion.  In  many  cases^ 
the  head  and  eyes  will  be  turned  in  the  same  direction,  and 
that  will  be  toward  the  side  of  the  lesion.  The  face  is  likely  to 
be  purple,  congested  ;  the  breathing  labored  and  often  stertor- 
ous. I  have  had  one  case,  in  my  experience,  in  which  the  face  was 
pale.  The  temperature  will  rise  to  from  102°  to  104°,  or  even 
to  107°  or  108°  Fahr.  If  it  goes  above  105°,  the  case  is  very 
serious,  and  death  is  likely  to  result.  The  pulse  at  first  is 
apt  to  be  increased  in  frequency,  but  soon  becomes  slow  and  full. 
Paralysis  may  be  noticed  during  the  coma,  or  more  frequently 
immediately  after  the  return  of  consciousness. 

If  initiated  by  a  convulsion,  the  convulsive  movements  may 


EMBOLISM.  681 

or  may  not  be  confined  to  the  muscles  which  are  subsequently 
to  become  paralyzed. 

The  paralyzed  muscles  may  show  slight  contractions  very 
soon.  Wasting  from  non-use,  and  arrest  of  development,  more 
or  less  complete  in  the  paralyzed  muscles,  is  always  present  as 
the  case  progresses. 

The  tendon  reflexes  will  be  exaggerated  in  the  paralyzed 
limbs,  the  electrical  reaction  will  be  unchanged  until  such  time 
as  degeneration  of  muscle  tissue  takes  place.  The  reaction  of 
secondary  degeneration  will  not  be  present  even  then.  Apha- 
sia and  mental  disturbances  are  often  present.  In  nearly  all 
these  cases,  associated  movements,  athetoid  movements,  or 
chorea-form  movements,  will  supervene  sooner  or  later.  The 
paralysis  is  usually  in  the  form  of  a  hemiplegia.  The  face  may 
or  may  not  be  implicated.  There  are  a  few  cases  in  which 
there  is  a  paraplegia  of  either  the  arms  or  the  legs,  and  occa- 
sionally a  monoplegia.  In  nearly  all  cases,  a  partial  recovery 
takes  place  naturally ;  first  the  leg,  then  the  arm,  and  lastly,  if 
affected  at  all,  the  face.  This  recovery  continues  to  some  in- 
definable point  and  then  ceases.  The  accompanying  contrac- 
tures appear  early  and  are  persistent ;  they  are  at  times  so 
severe  as  to  render  the  limb  entirely  useless.  The  flexor  and 
adductor  muscles  are  more  frequently  affected  than  the  exten- 
sor and  abductors.  Convulsive  seizures  are  quite  common 
through  the  balance  of  life,  although  there  are  a  goodly  num- 
ber of  cases  in  which  they  never  occur  ;  they  may  be  general, 
confined  to  one  side,  or  to  a  single  extremity. 

Diagnosis. — The  diagnosis  of  cerebral  paralysis  is  compara- 
tively easy,  but  the  distinction  as  to  the  producing  lesion  re- 
quires some  special  attention.  In  children  the  presumption  is 
in  favor  of  meningeal  or  cortical  lesion,  as  they  are  far  the  most 
common  causes  of  paralysis  in  children.  If  the  coma  be  marked 
and  prolonged,  and  there  be  convulsions  occurring  very  fre- 
quently, it  is  probably  meningeal.  If,  on  the  other  hand,  the 
coma  is  very  slight,  of  short  duration,  and  there  is  but  one  con- 
vulsion, it  is  probably  in  the  interior  of  the  brain  or  capsular. 
Early  and  marked  mental  defects  point  to  meningeal  or  corti- 
cal lesion.  Hemiplegia  without  involving  the  face  is  cortical. 
If  there  be  convulsive  movements  in  the  paralyzed  part,  it  is 
probably  cortical.  Abnormality  or  irregularity  in  the  shape  of 
the  cranium  points  to  cortical  lesion.  Those  cases  produced 
by  the  diseases  mentioned  as  causative,  are  likely  to  be  intra- 
cranial. 

The  differentiation  between  hemorrhage,  thrombus  and  em- 
bolism, in  a  large  percentage  of  the  cases,  is  impossible.  If  there 
be  present  any  condition  in  which  an  embolus  may  exist,  and  the 


682  THE  DISEASES  OF  CHILDREN. 

initial  attack  is  very  sudden,  and  partial  recovery  very  rapid,  it 
is  probably  embolism.  If  there  is  such  a  condition  present  as 
to  render  probable  a  degeneration  of  the  blood-vessels,  and  the 
attack  is  not  markedly  sudden,  and  the  natural  recovery  slow, 
it  is  probably  thrombus ;  all  other  cases  are  probably  hemor- 
rhage. It  is  possible  that  we  may  have  a  condition  of  circum- 
scribed inflammation  and  destruction  of  function  in  small  areas 
of  the  cortex  similar  to  the  condition  found  in  the  anterior 
horns  in  polyomyelitis.  I  do  not  know  how  to  distinguish  this 
from  other  lesions.  In  tumor  the  headache,  vertigo,  and  pres- 
ence of  optic  neuritis  preceding  the  attack  will  enable  you  to 
differentiate. 

Prognosis. — As  to  the  prognosis  in  the  cases  occurring  after 
birth,  the  more  profound  and  long-lasting  the  coma,  the  higher 
the  temperature,  the  more  imminent  is  a  fatal  termination. 
Frequent  convulsive  attacks  are  very  unfavorable  to  life.  Any 
sign  of  returning  consciousness  is  favorable,  but  never  fail  to  call 
attention  to  a  possible  relapse  speedily  into  as  profound  a  coma 
as  ever.  During  the  coma  you  may  be  able  to  form  a  very  fair 
idea  as  to  the  extent  of  the  probable  resultant  paralysis.  When 
consciousness  is  entirely  restored,  and  the  temperature  normal  or 
nearly  so,  you  can  safely  predict  that  the  general  health  will  prob- 
ably be  restored.  You  cannot,  however,  predict  what  the  mental 
condition  will  be  ;  this  you  can  only  judge  of  as  the  weeks  go 
by.  It  is  safe  to  call  attention  to  the  fact  that  there  may  be 
absolute  idiocy  ;  that  the  mentality  may  be  arrested  at  this 
point,  that  it  may  be  simply  retarded  in  its  development,  or 
that  it  may  not  be  affected  at  all. 

As  to  the  progress  of  the  paralysis,  if  from  a  hemorrhage, 
bear  in  mind  that  there  is  very  soon  formed  a  clot,  the  extent 
of  which  is  determined  by  the  extent  of  the  paralysis.  This 
clot  will  ■  soon  shrink  in  size,  thus  causing  an  improvement  in 
the  extent  and  completeness  of  the  paralysis ;  the  clot  is  then 
encysted  and  begins  to  degenerate.  The  contents  of  the  cyst 
finally  being  entirely  absorbed,  the  walls  close  together  and 
form  a  cicatrix.  During  this  process  gradual  improvement  in 
the  paralysis  will  take  place.  If  the  contractures  are  marked 
and  persistent,  there  is  not  only  pressure,  but  irritation  present, 
and  there  is  less  likelihood  of  complete  recovery. 

The  cicatrix  is  often  entirely  absorbed,  so  that  an  autopsy  a 
few  years  later  will  fail  to  reveal  any  signs  of  the  original  hem- 
orrhage. 

While  in  a  certain  number  of  cases  there  is  practically  a  per- 
fect recovery,  in  many  there  has  been  sufficient  permanent 
damage  done  to  the  brain  tissue  to  prevent  its  ever  returning  to 
a  normal  functional  activity.     In  these  cases  a  certain  amount 


EMBOLISM.  683 

of  paralysis,  contracture  and  slowness  of  development  will  al- 
ways exist  to  the  end.  Always  bear  in  mind  that  if  the  initial 
attack  is  indicative  of  profound  cerebral  lesion,  even  if  there  be 
comparatively  little  motor  disturbance,  that  it  is  possible  to 
have  extensive  lesion  of  the  occipital  or  frontal  regions  without 
marked  paralysis,  and  in  these  cases  the  prognosis  respecting 
the  m.entality  is  very  unfavorable. 

In  thrombus,  remember  a  greater  or  less  portion  of  the  brain 
is  cut  off  from  circulation,  that  there  is  a  tendency  to  degener- 
ative action,  that  restoration  can  only  take  place  through  col- 
lateral circulation,  that  therefore  the  chances  of  a  complete 
recovery,  or  of  rapid  progress,  are  not  nearly  so  favorable. 
There  is  more  probability  that  a  secondary  softening  involving 
the  areas  deprived  of  circulation  will  occur. 

In  embolism,  remember  that  there  is  no  pressure,  that  in  a  cer- 
tain number  of  cases  the  force  of  the  circulation  will  break  up  the 
plug  and  carry  the  particles  to  destruction,  and  a  complete  and 
early  recovery  take  place  ;  that  the  blood-vessels  and  surround- 
ing tissues  are,  at  the  onset,  in  a  normal  condition,  thus  allow- 
ing opportunity,  except  in  a  case  of  terminal  vessels,  for  free 
collateral  circulation.  By  this  means  the  area  cut  off  from  cir- 
culation is  soon,  to  a  greater  or  less  degree,  restored  to  nutri- 
tion and  to  functional  activity,  and  the  prognosis  is  rendered 
proportionately  favorable  as  to  rapidity  and  completeness 
of  recovery.  It,  however,  is  never  wise  in  any  case  to  be  pro- 
fuse in  promises  of  recovery  ;  no  man  knows  what  change  may 
take  place  in  a  day  to  materially  alter  the  patient's  prospects. 
In  the  congenital  cases  the  prognosis  is  always  grave,  the 
chances  for  recovery  from  the  paralysis  are  very  slight,  and  con- 
vulsions are  almost  certain  to  be  frequent  and  severe,  and  the 
mentality  almost  certain  to  be  of  a  very  low  grade.  There  are 
exceptions — that  is,  a  few  cases  have  grown  up  with  fair  mental- 
ity, and  some  free  from  convulsions. 

Treatment.  —  In  regard  to  the  treatment  of  hemorrhage, 
thrombus  or  embolism,  in  the  congenital  cases,  your  first  efforts 
will  be  directed  to  establishing  and  maintaining  regular  respira- 
tion ;  this  at  first  must  be  accomplished  by  mechanical  means, 
such  as  artificial  respiration,  inflating  the  lungs  with  air,  and 
forcing  the  air  out  again  by  compression  at  regular  intervals. 
After  self- respiration  has  been  established,  lachesis  I2x  may 
be  of  benefit  in  assisting  regularity. 

In  the  cases  occurring  after  birth,  the  one  most  important 
thing  for  the  physician  to  remember  is.  that  he  can  easily  do 
too  much ;  the  parents  and  friends  are  anxious  that  something 
be  done,  and  not  infrequently  has  the  physician  jeopardized 
the  prospect  of  the  patient  on  account  of  the  importunity  of 


684  THE  DISEASES  OF  CHILDREN. 

parents  and  friends.  If  the  onset  is  a  convulsion,  the  ordinary- 
rule  to  put  the  child  in  a  hot  bath  is  dangerous  ;  therefore  study 
carefully  your  case  when  first  called  to  a  child  in  convulsions 
for  the  first  time.  If  the  temperature  is  high,  make  your  arrange- 
ments for  the  bath,  in  this  way  getting  every  one  about  busy, 
then  look  carefully  for  any  evidence  of  the  spasm  being  local 
instead  of  general,  also  for  any  evidences  of  paralysis ;  note 
carefully  the  character  of  the  respiration  and  of  the  pulse ;  if 
satisfied  that  cerebral  hemorrhage  or  thrombus  is  present,  give 
gelsemium  3X  if  the  child  be  under  one  year,  or  ix  if  under 
three  years,  and  from  one  to  two  drop  doses  of  the  tincture  if 
over  three  years  of  age.  Secale  cornutum  may  be  used  in  the 
same  doses.  Lachesis  I2x  or  cnprum  aceticum  3X  may  be 
indicated.  None  of  these  may  be  indicated ;  each  physician 
must  select  for  himself  the  indicated  remedy  in  the  individual 
case.  These  are  the  remedies  I  believe  most  frequently  needed. 
If  unable  to  control  the  convulsions  with  remedies  within  a 
reasonable  time,  chloroform  by  inhalation  ought  to  be  used,  of 
course  with  caution.  The  mixture  of  bromide  and  chloral  hy- 
drate, on  page  656,  may  be,  in  some  persistent  cases,  advisable, 
or  small  doses  of  chloral  hydrate  alone  may  be  used.  Hot 
sponging  may  be  of  service. 

If  the  onset  is  with  coma,  have  the  child  kept  very  quiet ;  do 
not  put  ice  on  or  about  the  head,  but  occasionally  tepid  body 
and  head  sponging  should  be  used,  if  the  temperature  does  not 
fall  within  a  few  hours.  If  the  rectum  is  loaded,  unload  it  by 
enema ;  aconite  3X  will,  I  think,  be  called  for  more  frequently 
than  any  other  remedy;  never,  under  any  circumstances,  give 
opium  to  a  child  under  seven  years  of  age;  if  older  than  seven, 
opium  IX  or  3X,  stramonium  3X,  or  nux  vomica  3X.  Keep  the 
patient  quiet  and  continue  the  selected  remedy  till  conscious- 
ness is  restored  ;  continued  or  rising  temperature  is  of  grave 
import.  Always  look  carefully  after  the  urinary  excretion  ;  if 
markedly  deficient,  helleboris  niger  ix  or  3X  will  probably  be 
the  best  remedy,  although  apis,  chavioviilla,  apocynum,  gel- 
semium, sweet  spts.  nitre,  or  other  remedies  may  be  indicated 
and  should  be  used.  After  the  convulsions  or  coma  are  relieved, 
you  can  do  no  better  than  to  watch  the  case  carefully  until  the 
natural  amelioration  is  well  established,  then  commence  a  line 
of  treatment,  lo'oking  to  the  prevention  of  contractures  and  the 
cure  of  the  paralysis. 

Cerebral  Tumors. — Tumors  of  the  brain  seem  to  be  as 
frequent  in  persons  under  nineteen  years  of  age  as  in  older  people; 
they  are  more  frequent  in  boys  than  in  girls :  they  may  occur 
in  any  portion  of  the  brain  or  membranes.     The  varieties  that 


CEREBRAL   TUMORS.  685 

have  been  diagnosticated  are  gumma,  tubercular,  carcinoma, 
cysts,  sarcoma,  glioma  and  glio-sarcoma.  Under  this  head  will 
also  be  included  intracranial  aneurism.  The  most  frequent  in 
young  children  is  the  tubercular.  The  most  common  location  of 
these  is  in  the  cerebellum  and  on  the  base.  They  are  very 
apt  to  be  multiple  and  distributed  irregularly  over  a  very 
large  area. 

Causes. — The  causes  of  cerebral  tumor  may  be  determined 
with  reasonable  certainty  in  acute  cases,  but  in  the  great  ma- 
jority, the  cause  is  a  mere  matter  of  speculation.  Heredity, 
undoubtedly,  is  an  important  factor  in  a  great  many  cases ;  di- 
rect blows  on  the  head  are  probably  the  immediate  cause  in  a 
good  many  instances.  Extension  of  tumors  of  the  ear,  nose, 
orbit  and  scalp,  or  even  from  the  pharynx  into  the  brain,  is 
occasional. 

Symptoms. — The  immediate  condition  of  the  cerebral  circu- 
lation has  a  direct  and  marked  effect  on  the  prominence  of  the 
symptoms ;  this  is  the  case  in  nearly  all  kinds  of  tumor,  but  of 
course,  is  much  more  marked,  the  more  vascular  the  tumor. 
The  importance  of  this  fact  is  that  it  enables  the  physician  to 
give  special  direction,  in  each  case,  to  avoid  all  those  things 
having  a  tendency  to  produce  sudden  changes  in  the  circulation 
of  the  brain.  In  a  large  number  of  the  cases,  the  earliest  symp- 
toms will  be,  in  quite  young  children,  a  loss  of  interest  in  its 
play  and  in  its  surroundings,  generally  a  disposition  to  lie  down 
and  keep  quiet,  with,  not  infrequently,  an  irritable,  fretful  dis- 
position, coupled,  in  many  cases,  with  somnolence.  Occasion- 
ally, there  is  a  marked  insanity  of  a  varying  degree  of  intensity, 
or  there  may  be,  in  the  course  of  the  disease,  absolute  imbe- 
cility. In  older  children,  the  mental  inactivity  also  shows 
itself  early,  but  more  uniformly  in  the  way  of  a  slow  percep- 
tion, comprehension  and  reasoning.  The  child  becomes 
stupid  and  dull,  and  may,  at  any  time,  become  maniacal  or 
melancholic.  Late  in  the  case,  there  is  quite  frequently  such  a 
degree  of  imbecility  that  the  child  pays  no  attention  to  defe- 
cation or  urination  whatever,  and  must  be  looked  after  just  like 
a  young  babe. 

In  nearly  every  case,  optic  neuritis  or  choked  disk  will  be 
present,  more  frequently  double  than  unilateral.  There  may, 
or  may  not,  be  associated  with  it  visual  defects ;  I  believe  this 
symptom  occurs  very  early  in  the  case  ;  it  has  enabled  us,  on 
occasions,  to  suggest  the  beginning  of  tumor  some  considerable 
time  before  there  were  other  symptoms  present,  sufficient  to 
cause  suspicion.  There  is  often  a  general  impairment  of  sight, 
and  the  field  of  vision  is  curtailed  in  some  special  direction,  or 
may  be,  in  all  directions. 


686  THE  DISEASES  OF  CHILDREN. 

Headache  is  almost  universal.  It  is  usually  present  before 
the  tumor  is  diagnosticated,  but  is  not,  I  think,  as  early  a  symp- 
tom as  either  of  the  preceding.  It  is  usually  produced  or  ag- 
gravated by  any  excitement  or  undue  exertion,  that  is,  by 
anything  that  causes  an  increased  volume  of  circulation  in  the 
brain.  It  is  often  intermittent,  may  be  regularly  periodical, 
and  increases  in  intensity  with  the  growth  of  the  tumor.  It 
may  be  a  dull,  heavy,  continuous  ache,  with  more  or  less  fre- 
quent exacerbations  of  great  severity.  It  is  usually  accompa- 
nied by  an  indefinable  sensation  in  the  head.  It  is  nearly  always 
referred,  either  to  the  frontal  or  occipital  region  ;  occasionally, 
though  rarely,  to  a  point  immediately  over  the  tumor.  If  there 
be  marked  tenderness  to  pressure  of  the  scalp  over  a  circum- 
scribed area,  persistent  headache  in  the  same  location,  and  the 
headache  is  aggravated  by  gentle  percussion  over  the  same 
area,  there  is  a  strong  supposition  that  the  tumor  is  cortical  or 
meningeal. 

General  convulsions  are  very  common  in  the  progress  of  a 
tumor;  they  may  be  of  any  degree,  from  the  slightest  twitching 
of  the  eyes  and  face,  to  the  severest  epileptoid,  with  pro- 
nounced and  prolonged  coma.  They  are  apt  to  appear  very 
early  in  the  case.  They,  at  first,  occur  with  long  intervals; 
later,  are  quite  apt  to  come  in  groups,  that  is,  there  will  be  a 
longer  or  shorter  period  between  them,  and  then  a  large  num- 
ber of  convulsive  seizures  a  day  for  a  considerable  time.  It  is 
generally  understood  that  these  periods  mark  a  rapid  growth 
of  the  tumor  or  an  effusion  into  the  ventricles.  Localized  con- 
vulsive seizures  may  occur,  depending  on  the  location  of  the 
tumor,  but  in  a  large  majority  of  cases,  the  convulsions  are 
general,  no  matter  where  the  tumor  is  located. 

Vomiting  is  quite  apt  to  occur  on  any  movement  of  the 
head, after  the  patient  has  been  confined  to  the  bed  sometime; 
it  may,  or  may  not,  be  accompanied  by  vertigo,  and  is  without 
reference  to  meals ;  there  may,  or  may  not,  be  nausea ;  it  is  not 
a  constant  symptom,  there  being  many  cases  in  which  it  is  not 
present. 

Vertigo,  if  present,  is  likely  to  occur  at  intervals  ;  the  room 
or  objects  swim  around  the  patient ;  there  is  possibly  a  sudden 
feeling  of  losing  the  balance,  as  if  about  to  fall,  or  a  feeling  of 
nausea  and  faintness  ;  the  patient  will  clasp  the  hand  over  the 
eyes  to  shut  out  the  light  and  surrounding  objects. 

Insomnia  of  various  degrees  is  very  often  present.  Local- 
izing symptoms  depend  absolutely  on  the  location  of  the 
tumor  in  the  brain  ;  they  progress  gradually,  and  often  irregu- 
larly. 

Localization. — Tumors   involving  the   cortex   of   the   hemi- 


CEREBRAL   TUMORS.  687 

spheres  produce  mental  irregularities,  headache,  tenderness  of 
the  scalp,  deep-seated  and  general  convulsions. 

If  in  the  frontal  lobes,  there  may  be  no  special  localizing 
symptoms ;  if  in  the  orbital  convolutions,  there  is  apt  to  be 
loss  of  smell  on  the  side  of  the  lesion.  If  a  case  presents  con- 
vulsive attacks  commencing  in  one  member  and  spreading  to 
others,  and  is  not  followed  by  paralysis,  even  temporary,  there 
is  a  suspicion  of  tumor  in  the  frontal  convolutions.  The  third 
frontal  convolution  will  give  motor-aphasia,  a  condition  in 
which  the  comprehension  of  language  is  nearly  intact,  but  the 
patient  can  neither  speak  nor  write  words. 

The  paracental  lobule  comprising  the  anterior  and  posterior 
border  of  the  fissure  of  Rolando,  the  motor  centers  of  the  brain, 
will  present  localizing  symptoms  clearly  defined,  and  important 
in  that  they  frequently  furnish  a  certain  guide  to  cure  through 
operative  means.  There  is  likely  to  be  some  paresthesia,  fol- 
lowed by  local  spasm,  it  in  turn  followed  by  paralysis.  The 
paralysis  is  at  first  in  most  cases  a  simple  weakness,  a  feeling  of 
heaviness  ;  there  is  gradual  increased  loss  of  power,  and  finally 
complete  paralysis.  In  many  cases,  while  the  progress  of  the 
paralysis  is  gradual,  it  is  not  regular,  but  in  distinct  stages. 
The  point  at  which  the  initial  sensation  or  spasm  begins,  prob- 
ably indicates  the  exact  location  of  the  brain  lesion  ;  that  is, 
the  spasm  is  apt  to  begin  in  the  exact  muscles  for  which  the 
diseased  point  is  the  cortical  center.  As  the  tumor  spreads,  the 
direction  of  growth  may  be  indicated  by  the  order  in  the  spread 
of  the  spasm.  The  paralysis,  as  the  tumor  increases  in  size, 
spreads  from  one  set  of  muscles  to  another,  till  in  nearly  every 
case  (unless  death  intervenes)  of  tumor  in  the  motor  area,  there 
is  a  complete  hemiplegia.  A  marked  paralysis  preceding  spasm 
is  indicative  of  hemorrhage,  an  accident  occasionally  occurring. 

It  is  impossible  to  distinguish  between  a  tumor  in  the  cortex 
and  one  of  the  white  substance  immediately  beneath  the  cortex. 

If  in  the  parietal  lobes,  there  is  nearly  always  a  disturbance 
of  the  pain  sense,  of  tactile  sensation,  of  muscle  sense,  and  of 
the  sensations  of  heat  and  cold.  If  the  tumor  be  in  the  inferior 
parietal  lobule  of  the  left  hemisphere,  the  patient  will  not  be 
able  to  recognize  printed  or  written  words,  can  write  from  dic- 
tation, but  not  without. 

Tumor  in  the  occipital  lobe  produces  defects  in  vision;  if  in  the 
right  occipital  there  will  be  blindness  in  the  left  half  of  both  eyes, 
the  patient  being  unable  to  see  anything  with  either  eye  to  the 
left  of  a  line  directly  in  front  of  him.  If  the  left  occipital  be 
the  seat  of  tumor,  there  may  be  in  addition  word  blindness. 
Irritation  in  the  occipital  lobe  gives,  in  many  cases,  hallucina- 
tions of  light.     Frequently  recurring  hallucinations  of  light, 


688  THE  DISEASES  OF  CHILDREN. 

followed  by  more  or  less  marked  convulsive  action,  especially  if 
unilateral,  and  even  temporary  blindness  indicates  clearly  irri- 
tation in  the  occipital  lobe.  If  in  the  tempero-sphenoidal  lobe, 
there  will  probably  be  present  word  deafness,  a  condition  in 
which  the  patient  understands  language  and  can  talk,  but  will 
be  unable  to  remember  names  of  persons  or  things,  perfectly 
familiar  to  him,  and  consequently  is  constantly  getting  wrong 
and  incongruous  words  into  his  sentences. 

If  located  in  the  sylvian  fissure,  it  may  produce  quite  exten- 
sive paralysis,  and  will  produce  paraphasia,  a  condition  in  which 
the  words  of  a  sentence  are  all  mixed  up,  and  the  conversation 
is  likely  to  be  unintelligible. 

Tumors  in  the  basilar  ganglia  are  exceedingly  difficult  to 
diagnosticate.  Optic  neuritis  is  almost  certain  to  be  present. 
Vomiting  and  vertigo  are  also  frequently  present.  General 
convulsive  attacks  are  not  common. 

Tumors  in  the  pons  varolii  are  likely  to  produce  bilateral 
symptoms  ;  if  in  the  upper  half  of  the  pons,  there  will  be  exter- 
nal strabismus  from  affection  of  the  third  and  fifth  nerve;  the 
pupil  will  be  dilated  and  ptosis  present ;  ulceration  of  the  cornea 
is  quite  frequent,  and  there  is  likely  to  be  pain,  anesthesia  and 
tingling  of  the  face.  If  the  tumor  be  in  the  lower  half  of  the 
pons,  the  sixth,  seventh,  and  eighth  nerves  are  the  ones  impli- 
cated, and  we  have  internal  strabismus,  contracted  pupil  and 
deafness,  with  vertigo ;  also  paralysis  of  the  face,  the  patient 
being  unable  to  close  the  eye.  These  eye  and  face  symptoms 
are  unilateral,  with  them  there  is  likely  to  be  present  paralysis 
and  anesthesia  of  arm  and  leg,  usually  not  complete ;  the  eye 
and  face  symptoms  will  be  on  the  same  side  as  the  lesion,  while 
the  paralysis  and  anesthesia  of  the  limbs  are  on  the  side  oppo- 
site the  lesion. 

If  located  in  the  medulla  oblongata,  the  glosso-pharyngeal, 
pneumogastric,  spinal  accessory,  and  hypo-glossal  are  the  nerves 
affected  ;  there  may  be  difficulty  in  swallowing,  irregular  respira- 
tion, irregular  or  intermittent  pulse,  flushing  of  the  skin,  pro- 
fuse sweating,  polyuria  or  glycosuria,  projectile  vomiting, 
retraction  of  the  head,  or  rolling  of  the  head  in  the  pillow, 
inability  to  protrude  the  tongue,  to  suck,  and  to  articulate ;  of 
course,  it  is  rare  to  find  all  the  symptoms  present  in  any  one 
case. 

The  prominent  local  symptoms  of  the  cerebellum  are  vertigo 
and  ataxy.  The  patient  is  likely  to  have  a  feeling  of  falling  or 
turning,  always  in  the  same  direction  ;  this  is  so  real  as  to  cause 
him  to  catch  hold  of  some  near  object  to  prevent  falling;  this 
sensation  with  vertigo  comes  in  distinct  attacks,  usually  accom- 
panied with  very  severe  headache.  There  is  also  a  characteristic 


CEREBRAL   TUMORS.  689 

ataxic  gait,  the  patient  staggers  very  much  as  if  intoxicated ; 
the  body  totters  from  side  to  side,  and  the  steps  are  uneven  in 
length  and  character.  There  is  often  a  tendency  to  veer  to- 
ward the  side  of  the  lesion  ;  the  patient  does  not  watch  the 
feet  as  in  locomotor  ataxy  ;  there  may  or  may  not  be  paralysis  ; 
if  present,  it  will  be  of  the  limbs  on  the  side  opposite  to  the 
lesion.  Hydrocephalus  is  a  common  occurrence  in  conjunction 
with  cerebellar  tumor. 

Diagnosis. — The  diagnosis  as  to  the  character  of  the  tumor 
must  be  made  from  general  considerations  of  the  characteristics 
of  each,  and  the  probable  predisposing  tendencies  in  the  family, 
or  in  the  patient. 

The  main  points  of  distinction  from  abscess  are :  Abscess 
often  follows  suppurative  disease  of  the  ear,  nose  or  orbit,  and 
caries  of  the  skull.  If  the  result  of  a  blow  on  the  head,  abscess 
is  likely  to  develop  quickly ;  there  is  fever  and  altogether  a 
picture  of  rapid,  profound  trouble ;  in  abscess,  the  progress  is 
apt  to  be  more  rapid  at  the  onset,  but  there  may  be  an  entire 
remission  of  all  symptoms  for  a  long  period,  and  then  a  sudden, 
severe,  fatal  return. 

In  chronic  hydrocephalus,  the  paralysis  will  be  of  the  spastic 
variety,  will  be  bilateral  and  without  local  spasm. 

Prognosis. — The  prognosis  is  positively  unfavorable,  except 
in  the  few  cases  that  can  be  clearly  localized,  and  are  so  situated 
as  to  admit  of  operation.  Death  may  be  sudden  from  a  hem- 
orrhage, or  the  patient  may  waste  away,  finally  go  into  a  pro- 
found coma,  have  frequent  convulsions,  and  die. 

In  syphilitic  tumors,  the  prognosis  may  be  much  more 
favorable. 

Treatment. — As  to  the  removal  of  cerebral  tumors,  if  they 
present  such  symptoms  as  to  be  clearly  and  certainly  located 
in  the  cortex  or  on  the  surface  of  the  brain  at  any  point,  or  in 
the  fissures  of  Rolando  or  of  Sylvius,  it  is  possible  to  operate, 
provided  they  are  not  of  such  character  as  to  render  necessary 
the  destruction  of  too  large  an  area  of  brain  tissue.  It  will  be 
found,  however,  that  a  very  small  percentage  present  a  suffi- 
ciently clear-cut  line  of  symptoms,  to  make  the  localization  at. 
all  certain.  My  practice  is  never  to  operate  unless  the  case  is 
clear  cut. 

The  general  treatment  consists  in  hygienic  and  sanitary 
measures ;  good  full  nutrition,  the  keeping  of  the  circulation, 
especially  the  portal  circulation,  in  the  best  possible  condition, 
and  in  directing  the  avoidance  of  such  things  as  tend  to  increase 
the  blood  pressure  in  the  brain. 

If  the  tumor  be  tubercular,  cod-liver  oil  or  other  fatty  nutri- 
ments should  be  used. 
D.  C— 44 


690  THE  DISEASES  OF  CHILDREN. 

In  syphilitic  tumors,  the  iodid  of  potassium  has,  without 
question,  produced  a  good  many  cures ;  I  know  of  no  other 
remedy  that  has.  I  do  not  use  the  mercurial  treatment  at  all  in 
these  cases ;  I  use  the  iodid  of  potassium,  commencing  with 
five  grains  in  a  half  a  drachm  of  water,  three  times  a  day,  prefer- 
ably before  meals,  gradually  increasing  the  size  of  the  dose  till, 
in  patients  over  ten  years  of  age,  they  get  from  thirty  to  forty 
grains  three  times  a  day.  In  younger  patients,  from  fifteen  to 
twenty-five  grains  three  times  a  day.  If,  at  any  tirr.e,  the  drug 
produces  marked  disturbance  of  the  stomach,  I  stop  it  for  a 
week,  and  give  from  one  to  three  grain  doses  of  bismuth  sub- 
nitrate,  and  then  commence  the  iodide  again,  with  about  one- 
half  the  last  dose,  and  again  increase  to  the  maximum.  There 
is  no  use  in  exhibiting  this  drug  unless  you  follow  it  up  per- 
sistently and  in  large  doses.  I  make  no  apology  for  this  line 
of  treatment.  When  I  learn  of  any  other  that  can  be  relied 
upon,  I  am  willing  to  accept  it. 

For  the  tubercular  tumors,  calcarea  iodid,  3x  trituration ; 
calcarea  carb.  30c  ;  a.nd ^uacum,  ix  trituration,  have  seemed  to 
give  me  good  results.  I  have  tried  many  others,  but  outside 
of  these,  have  failed  to  get  benefit  in  any  well-marked  case  of 
cerebral  tumor. 

Spinal  Paralysis. — Anything  that  produces  pressure  or 
destruction  of  the  tissues  of  the  spinal  cord  may  produce  paral- 
ysis in  the  muscles  supplied  by  the  cord.  The  paralysis  may 
be  in  the  form  of  paraplegia,  usually  of  the  lower  extremities, 
occasionally  of  the  upper,  less  frequently  of  both  upper  and 
lower.  One  entire  limb  may  be  paralyzed,  or  it  may  be  con- 
fined to  an  individual  muscle  or  set  of  muscles ;  it  is  accom- 
panied by  atrophy  of  the  paralyzed  muscles,  and  by  diminution 
or  loss  of  the  tendon  reflexes;  the  superficial  or  cutaneous 
reflexes  are  also  usually  interfered  with ;  in  many  cases,  cuta- 
neous sensation  is  diminished  or  destroyed  ;  the  urinary  and 
rectal  reflexes  are  frequently  interfered  with.  The  extent  of 
the  paralysis  and  the  sensory  symptoms  are  directly  dependent 
on  the  location,  character,  and  extent  of  the  lesion  in  the  cord. 

Fracture  or  dislocation  of  the  spinal  column  in  such  a  way  as 
to  compress  the  cord  in  its  entire  transverse  section  at  any 
point,  will  produce  complete  bilateral  paralysis  of  both  motion 
and  sensation  of  all  muscles  below  the  point  of  injury.  If  high 
enough  up  in  the  column,  will  produce  paralysis  of  the  muscles 
of  respiration  and  heart,  causing  instant  death. 

There  may  be  fracture  of  the  spinous  processes,  or  of  the 
arch  of  the  vertebrae  in  such  a  manner  as  to  lacerate  or  impinge 
on  a  single  trace,  or  a  portion  only  of  the  transverse  section  ;  in 


SPINAL  PARALYSIS.  691 

these  cases  the  symptoms  will  depend  on  the  exact  location 
and  extent  of  the  cord  lesion. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of  an  in- 
jury of  such  nature  as  to  render  fracture  or  dislocation  prob- 
able or  possible,  and  the  presence  of  motor  and  sensory  symp- 
toms referable  to  lesion  of  the  cord. 

Treatment. — The  treatment  in  these  cases  must  depend  in  a 
great  measure  on  the  judgment  of  the  attending  physician  ;  the 
patient  may  be  put  to  bed  on  an  air  or  water  mattress,  mechan- 
ical appliance  used  to  hold  the  column  firmly  in  position,  an 
operation  may  be  performed,  cutting  down  on  to  the  vertebra, 
and  either  removing  or  replacing  the  misplaced  bone.  For  the 
details  of  the  treatment  you  will  go  to  your  works  on  surgery. 

I  have  seen  several  cases  where  I  am  fully  convinced  there 
had  been,  by  a  sudden  jerk,  a  dislocation  producing  injury  to 
the  cord,  and  where  the  dislocation  was  only  for  a  few  seconds, 
it  being  immediately  reset,  either  by  muscular  reaction  or  the 
peculiarities  of  the  accident,  leaving  the  evidences  of  the  cord 
lesion. 

In  examining  a  case  of  spinal  paralysis,  note  with  care  the 
condition  of  coordination,  the  tone  of  the  muscles,  the  condition 
of  the  reflexes,  tendon  and  superficial,  the  muscular  sense,  the 
electrical  reaction  of  the  muscles,  the  trophic  condition  of  the 
muscles,  or  of  a  paralyzed  limb,  the  degree  and  exact  distribu- 
tion of  the  paralysis. 

The  localizing  of  lesions  in  the  cord  will  be  materially  facili- 
tated by  quoting  from  Bramwell  the  functions  of  the  spinal 
nerve  roots  : 

Fourth  Cervical. — Flexion  of  the  forearm,  with  supination 
and  extension  of  the  wrist  and  fingers,  the  upper  arm  raised 
upwards  and  backwards. 

Fifth  Cervical. — Movement  of  the  hand  towards  the  mouth, 
viz.,  raising  the  upper  arm  inwards,  flexion  of  the  forearm,  with 
supination  and  extension  of  the  wrist  and  fingers. 

Sixth  Cervical. — The  movement  of  attention,  vis.,  adduction 
and  retraction  of  the  upper  arm,  extension  of  forearm,  pronation 
towards  the  pubes. 

Seventh  Cervical. — The  spinctu  ani  action,  viz.,  adduction 
and  rotation  inward,  and  retraction  of  the  upper  arm,  extension 
of  the  forearm  and  flexion  of  the  wrist  and  fingers  so  as  to  bring 
the  tips  against  the  flank. 

Eighth  Cervical. — Closure  of  the  fist  with  pronation  by  ulnar 
flexion  of  wrist,  retraction  of  the  arm  with  extension  of  the 
forearm. 

First  Dorsal. — Action  of  the  intrinsic  muscles  of  the  hand, 
muscles  of  ball  of  thumb,  interossei,  etc. 


C92  THE  DISEASES  OF  CHILDREN'. 

Functions  of  the  nerve  roots  of  the  lumbar  enlargement 
(according  to  Professors  Ferrier  and  Yeo,  from  observations 
made  on  monkeys;  and  MM.  Paul,  Bert,  and  Marcacci,  from 
observations  made  on  cats  and  dogs)  : 

First  Lumbar. — Determines  contraction  of  the  sartorius,  rec- 
tus, and  psoas,  which  flex  the  hip  upon  the  trunk.  (P.,  B. 
and  M.) 

Second  Lumbar. — Excites  contraction  of  the  anterior  portion 
6f  the  vastus  externus,  a  part  of  the  tensor  of  the  fascia  lata, 
and  the  vastus  internus — viz.:  the  muscles  which  extend  the 
leg  or  the  thigh.     (P.,  B.  and  M.) 

Third  Lumbar. — Similar  to  that  of  the  second,  with  some 
differences  in  detail.  It  excites  part  of  the  vastus  externus 
and  the  anterior  part  of  the  biceps,  which  is  an  extensor,  while 
the  posterior  portion  is  a  flexor. 

According  to  Ferrier  and  Yeo,  stimulation  of  the  third  lum- 
bar in  the  monkey  causes  flexion  of  the  thigh  and  extension  of 
the  leg. 

Fourth  Lumbar,  according  to  MM.  Paul  and  Marcacci, 
causes,  in  the  cat  and  dog,  movements  in  the  posterior  part  of 
the  biceps,  the  semi-tendinosus,  and  the  semi-membranosus 
(flexes  of  the  leg  or  the  thigh),  the  second  and  third  adductions 
of  the  thigh  and  the  extensors  of  the  thigh.  It  thus  inner- 
vates three  kinds  of  movements,  which  are  in  no  respect  op- 
posed or  contradictory. 

According  to  Professors  Ferrier  and  Yeo,  irritation  of  the 
fourth  root,  in  the  monkey,  causes  extension  of  the  thigh, 
extension  of  the  leg,  and  pointing  of  the  great  toe. 

Fifth  Root. — MM.  Bert  and  Marcacci  find  that,  in  the  dog 
and  cat,  the  fifth  root  presides  over  the  movements  of  the  tail. 

According  to  Ferrier  and  Yeo,  irritation  of  the  fifth  root  in 
the  monkey,  produces  outward  rotation  of  the  thigh,  flexion 
and  inward  rotation  of  the  leg,  plantar  flexion  of  the  foot,  and 
flexion  of  the  distal  phalanges. 

First  Sacral. — Flexion  of  the  leg,  plantar  flexion  of  the  foot, 
flexion  of  all  the  toes  at  the  proximal  phalanges,  and  also  of 
the  distal  phalanx  of  the  hallux.     (F.  and  Y.) 

Second  Sacral. — Action  of  the  intrinsic  muscles  of  the  foot, 
viz.:  adduction  and  flexion  of  the  hallux,  with  flexion  of 
the  proximal  phalanges  and  extension  of  the  distal.  (F. 
and  Y.) 

In  any  case,  having  determined  what  movements  can  be  per- 
formed and  what  group  or  groups  of  muscles  are  paralyzed,  you 
will,  by  reference  to  the  functions  quoted  above,  be  able  to 
locate  the  segment  or  segments  of  the  cord,  in  which  the  lesion 
is  to  be  found. 


ACUTE  IDIOPATHIC  MYELITIS.  693 

Potts'  Disease. — Potts'  disease  of  the  spine  is,  not  infre- 
quently, a  cause  of  a  paraplegia.  In  these  cases,  it  is  a  result 
of  an  extension  of  inflammation  from  the  bone  to  the  mem- 
brane, and  to  the  cord,  or  of  pressure  on  the  root  nerves  of  the 
cord,  from  displacement  of  the  vertebrae.  In  some  cases,  there 
may  be  a  discharge  of  pus  within  the  canal,  producing  pres- 
sure, and  in  a  few  instances,  a  hemorrhage  is  caused  in  the 
canal,  producing  pressure. 

A  more  or  less  regular  elevation  of  temperature,  increase  in 
the  rapidity  of  the  pulse,  tenderness  over  one  or  more  spinous 
processes,  or  an  irregularity  in  the  prominence. of  one  or  more 
of  the  spinous  processes,  and  the  characteristic  rigidity  of  the 
body,  point  to  a  Potts'  disease. 

For  the  points  of  diagnosis  and  the  treatment,  refer  to 
your  works  on  surgery.  The  object  in  mentioning  it  here  is, 
that  this  cause  of  paraplegia  shall  not  be,  as  it  so  often  is, 
overlooked.  In  many  cases  of  paraplegia  from  this  cause,  the 
paralysis  has  been  instantly  cured  by  extension  and  fixation  of 
the  spine. 

MYELITIS. 

Myelitis  or  inflammation  of  the  spinal  cord  may  result  from 
caries  of  the  vertebrae,  from  other  forms  of  traumatism,  from 
extension  of  meningeal  inflammation,  from  extension  inward  of 
neuritis,  or  by  transmission  of  irritation  over  a  nerve  trunk 
from  a  distant  point,  or  from  the  genital  organs  or  the  rectum. 
It  may  be  idiopathic,  or  may  be  caused  by  exposure  to  cold  and 
dampness. 

Acute  Idiopathic  Myelitis. — 5jw//^»«.— Is  usually  ush- 
ered  in  with  a  chill  followed  by  a  high  fever,  severe  pain  in  the 
back  and  also  in  the  abdomen,  rigidity  of  the  muscles  of  the 
abdomen,  retention  of  urine,  sharp  lancinating  pains  running 
along  the  course  of  the  spinal  nerves,  emerging  from  the  seat  of 
inflammation,  and  paralysis  of  motion  and  sensation  in  both 
legs. 

The  pain  in  the  back  is  increased  by  the  application  of  heat 
over  the  spine,  apt  to  be  relieved  by  hot  applications  over  the 
abdomen.  The  urine  soon  becomes  alkaline  and  must  be  drawn 
with  a  catheter,  as  there  is  great  liability  to  a  secondary  cys- 
titis. The  inflammation  is  prone  to  extend  lengthwise  of  the 
cord  very  rapidly.  If  termination  is  not  speedily  fatal,  the 
high  fever  is  likely  to  continue  from  one  to  two  weeks,  subsid- 
ing gradually,  and  leaving  the  patient  with  a  chronic  myelitis 
and  the  accompanying  paraplegia.  A  complete  cure  is  possible, 
leaving  no  sequela. 


694  THE  DISEASES  OF  CHILDREN. 

Treatment. — The  treatment  during  the  acute  stage  must  be 
conducted  with  promptness  and  vigor,  great  care  must  be  used 
to  prevent  bed-sores,  which  are  very  Hable  to  occur  ;  keep  the 
patient  in  a  semi-recumbent  position,  cold  applications  over  the 
spine  continuously.  In  the  severest  cases,  the  spinal  ice-bag  may 
be  advisable. 

The  galvanic  current  should  be  applied  downward  over  the 
spine,  using  from  ten  to  twelve  milleamperes  ;  each  application 
should  be  about  five  minutes;  repeat  the  application  every  hour 
or  two,  depending  on  the  severity  of  the  case. 

My  favorite  remedies  at  the  onset  z.x&  gelsemiutn,  ergot,  aco- 
nite. If  I  find  that  the  disease  is  extending  upwards  toward  the 
upper  dorsal  and  cervical  region,  and  (bear  in  mind  it  may  extend 
the  entire  length  of  the  cord  in  a  few  hours),  the  respiration  be- 
gins to  be  aflected,  and  there  seems  to  be  no  chance  of  arresting 
its  progress,  I  put  on  a  Spanish-fly  plaster,  and  draw  a  blister 
about  one  inch  wide  along  each  side  of  the  spinous  processes 
along  the  affected  region.  A  girdle  feeling  around  the  body, 
or,  if  the  patient  be  unable  to  describe  it,  you  will  be  able  to 
detect  it,  as  the  upper  border  of  abdominal  muscle  tension 
marks  the  upper  border  of  inflammation.  This  may  not  be 
good  practice  ;  there  may  be  better  and  surer  ways  to  arrest  the 
progress  and  diminish  the  inflammation,  but  as  time  in  these 
cases  is  very  precious  ;  as  an  hour  even  may  determine  unalter- 
ably the  result — and  I  know  of  no  more  speedy  methods  of 
nearly  equal  efificacy,  I  use  and  advise  it. 

If  at  the  onset  I  find  a  temperature  of  104°  Fahr.,  or  higher, 
with  a  very  rapid,  full,  unyielding,  hard  pulse,  I  invariably  give 
tincture  of  veratrum  viridc,  in  from  one  to  four  drop  doses, 
depending  on  the  age  of  the  child.  I  give  it  in  water,  repeat 
the  dose  every  fifteen  minutes  to  half  an  hour,  remain  by  the 
bedside,  and  keep  my  finger  on  the  pulse  until  it  becomes  soft 
and  does  not  exceed  from  70  to  80  per  minute.  I  am  so  par- 
ticular in  this  that  I  never,  under  any  circumstances,  leave  the 
bedside  until  time  to  stop  the  veratrum. 

When  all  evidence  of  progression  has  ceased,  attention  should 
be  given  to  the  reduction  of  acute  inflammation  as  speedily  as 
possible.  If  the  acute  inflammation  can  be  arrested  before  any 
destructive  process  in  the  cord  has  commenced,  we  will  have, 
very  soon,  a  subsidence  of  the  paralysis,  and  a  gradual  return 
of  both  sensation  and  motion  in  the  legs.  There  may  be  left 
irregularities  in  the  heart  action,  and  a  form  of  paralysis  be- 
longing to  the  spastic  variety,  in  which  there  is  an  inclination 
of  the  limb  to  remain  in  any  position  in  which  it  may  be  placed, 
or  there  may  be  a  simple  spastic  paraplegia,  or  a  flaccid  form  of 
paralysis. 


CHRONIC  Ml'E LITIS.  695 

The  remedies  most  likely  to  be  of  use  after  the  inflammation 
begins  to  subside,  as  shown  by  lowering  of  the  temperature 
and  lessening  of  the  pulse,  are  :  aconite  3X,  gelsemium  tmcture, 
cimicifuga  tincture,  physostigtna  3X,  manganese  3X,  oxalic  acid 
3x,  cannabis  ind.  3X,  and  kali  iod.  3X,  given  according  to  their 
special  indications.  The  galvanic  current  can,  with  advantage, 
be  continued  right  through  the  entire  course  of  the  disease. 
After  progress  is  arrested,  it  may  be  given  about  twice  a  day, 
till  the  temperature  and  the  pulse  are  nearly  normal,  then  once 
a  day — the  method  and  strength  as  indicated  for  onset. 

Prognosis. — It  is  always  well,  as  soon  as  the  nature  of  the 
case  is  determined,  to  say  to  the  parents  or  friends,  that  it  is  a 
case  in  which  you  cannot  promise  to  save  the  life,  and,  that 
the  chances  are,  that  there  will  be  a  long-continued  or  perma- 
nent paralysis  of  both  legs ;  also  that  there  is  danger  of  a 
cystitis. 

Chronic  Myelitis. — If  the  paraplegia,  following  acute  my- 
elitis, does  not  disappear  within  a  very  few  weeks,  we  have  a 
chronic  myelitis.  The  chronic  myelitis  frequently  occurs  with- 
out being  preceded  by  any  acute  attack ;  it  may  be  produced 
as  a  result  of  congenital  or  acquired  syphilis,  may  be  tubercu- 
lar, or  from  other  sources  previously  mentioned  as  causes  of 
myelitis. 

It  is  impossible,  as  a  rule,  to  determine  the  points  essential 
to  differentiation  of  the  various  forms  of  chronic  myelitis  in 
children.  I  shall  simply,  therefore,  outline  the  general  symp- 
toms. 

Symptoms. — It  usually  comes  on  very  gradually ;  there  is 
likely  to  be  first  noticed  a  weakness  of  the  legs.  The  child  is 
apt  to  complain  of  funny  feelings,  sometimes  of  sharp  pain  in 
different  parts  of  the  legs,  or  occasionally  a  feeling  as  if  the 
legs  were  asleep.  From  older  children,  we  are  usually  able  to 
get  a  fairly  correct  idea  of  the  kind  of  sensation,  but  in  most 
instances,  we  are  unable  to  get  anything  definite  as  to  anesthe- 
sia, hyperesthesia,  or  band  sensation.  We  can  only  obtain 
information  as  to  the  motor  symptoms  we  can  observe.  There 
will  usually  be  difficulty  in  emptying  the  bladder  and  obstinate 
constipation  ;  the  motor  weakness  increases  until  there  is  abso- 
lute paralysis  of  both  legs,  and  also  of  the  vescical  and  anal 
sphincters. 

The  trophic  conditions  of  the  paralyzed  muscles,  the  condi- 
tion of  the  tendon  and  cutaneous  reflexes,  as  well  as  the  pecul- 
iarity of  all  the  symptoms,  necessarily  depend  on  the  exact 
location  and  extent  of  the  lesion. 

The  paraplegia  is  more  often  of  the  flaccid  character,  accom- 


696  THE  DISEASES  OF  CHILDREN. 

panied  by  lowered  cutaneous  sensations  or  anesthesia,  and 
atrophy  of  the  paralyzed  muscles  ;  but  in  some  cases,  there  will 
be  a  spastic  paraplegia,  with  cutaneous  hyperesthesia,  and  with- 
out any  atrophy.  If  the  paralysis  becomes  complete,  and  the 
patient  is  bedridden,  bed  sores  are  very  likely  to  occur. 

There  is,  at  all  times,  danger  of  cystitis  from  retained  urine, 
and  of  extension  of  inflammation  from  the  bladder  to  the  kid- 
neys.    Respiratory  and  heart  complications  are  quite  common. 

Diagnosis. — The  lesions  from  which  chronic  myelitis  is  to  be 
distinguished  in  children,  are  primary  lateral  sclerosis,  Potts* 
disease  and  functional  paraplegia. 

Prognosis. — A  cure  can  hardly  be  promised,  but  a  hope  of 
arrest,  and  even  of  improvement,  may  be  entertained.  Cures 
are  reported  by  others,  and  have  occurred  in  my  own  practice. 

Treatment. — My  treatment  consists  in  spinal  extension,  elec- 
tricity, dry  cupping  over  the  spine,  nerve  vibration,  massage 
and  remedies.  The  remedies  I  use  are :  manganese  3X,  ergot 
(Squibb's  fl.  ext.),  in  from  three  to  ten-drop  doses,  three  or  four 
times  a  day ;  cannabis  ind.  30c,  argentum  chloride,  3X  tritura- 
tion, oxalic  acid,  3X  trituration,  calabar  bean,  3X  and  30c,  the 
\z.x'\o\xs,  salts  of  potash  in  the  3X  to  the  I2x  triturations,  and 
strychnia  30c,  according  to  indications.  I  have  never  been 
able  to  see  any  results  from  the  administration  of  mercury  in 
any  of  these  cases,  even  when  of  syphilitic  origin. 

Electricity :  I  use  the  galvanic  current,  apply  a  downward 
current  of  from  five  to  ten  milleamperes,  daily. 

Spinal  extension  :  I  use  Sayers' apparatus,  with  neck  and  arm 
supports,  raise  the  patient  so  that  the  feet  just  clear  the  floor, 
daily.  The  first  three  or  four  days  for  fifteen  seconds,  increase 
the  time  of  suspension  gradually  until  it  is  about  ninety  seconds. 

Dry  cupping  is  used  directly  over  the  affected  portion  of  the 
spine  daily ;  allow  the  cups  to  remain  from  five  to  fifteen  min- 
utes. The  surface,  for  some  time  after  the  removal  of  the  cups, 
is  likely  to  be  discolored  quite  markedly.  In  cases  where  there 
is  atrophy  and  a  low  circulation  in  the  legs,  the  vacuum  boot 
is  often  of  great  service. 

Nerve  vibration  is  to  be  applied  daily,  over  each  spinous 
process,  for  about  ten  seconds,  as  nearly  as  possible  at  the  same 
time  of  day  ;  commence  at  the  cervical  region  and  go  down  the 
spine. 

Anterior  Polyomyelitis,  more  commonly  known  as  In- 
fantile Spinal  Paralysis,  is  a  focal,  localized  or  circumscribed 
myelitis.  The  lesion  is  confined  to  the  anterior  cornua  of  one 
segment  usually,  but  three  or  four  segments  maybe  implicated. 
In    most  cases,  there  is   but  one   focus  of  inflammation  in  a 


ANTERIOR  POLTOMTELITIS.  69T 

segment,  but  in  a  few  cases,  both  anterior  horns  are  affected ; 
then  again,  there  may  be  two  or  three  distinct  foci  in  different 
and  separated  segments  of  the  cord. 

Causes. — In  a  great  majority  of  the  cases,  no  cause  can  be 
assigned.  The  neuropathic  heredity,  exposure  to  damp  and 
cold,  injury  and  reflex  irritation  are  the  most  common  assigna- 
ble causes. 

Symptoms. — We  recognize  a  form  that  seems  to  be  func- 
tional and  is  entirely  dependent  on  reflex  irritation  ;  it  usually 
appears  in  conjunction  with  teething,  or  as  a  result  of  genital 
irritation.  In  these  cases  the  onset  is  quite  frequently  accom- 
panied with  some  febrile  disturbance,  or  a  mild  convulsion,  or 
irritability.  It  is  noticed  suddenly  .that  the  child  does  not 
move  a  leg  or  an  arm ;  that  when  you  take  hold  of  the  mem- 
ber, it  is  limp,  and  offers  no  resistance  to  being  moved  in  any 
direction. 

When  called  to  a  case  of  this  kind,  you  will  note  the  absence 
of  any  indications  of  cerebral  disturbance  ;  that  there  is  no  tend- 
ency to  contracture  or  to  resistance.  Examine  as  to  the  con- 
dition of  the  gums,  also  as  to  the  condition  of  prepuce  or 
clitoris.  If  you  find  any  sufficient  cause  for  reflex  irritation,, 
there  is  a  reasonable  chance  that,  in  a  few  days,  motion  will 
begin  to  return  to  the, paralyzed  member,  that  no  atrophy  will 
take  place,  and  that,  in  a  few  weeks,  the  child  will  be  perfectly 
sound.  It  is  probable  that  in  these  cases,  there  is  sufficient 
local  congestion  in  certain  anterior  cornua  to  prevent  function, 
but  no  inflammation  to  produce  destruction.  Of  course,  any 
source  of  reflex  irritation  should  be  removed  at  once. 

The  onset  of  true  polyomyelitis  is  usually  sudden,  is  most 
frequent  between  the  second  and  ninth  year,  although  no  age 
is  absolutely  exempt.  The  child  goes  to  bed  apparently  in 
perfect  health;  in  the  morning  it  is  found  that  one  foot,  one 
leg  below  the  knee,  the  thigh,  or  the  entire  leg  and  foot,  or  a 
hand,  forearm,  upper  arm,  or  the  entire  arm  and  hand,  or  it 
may  be  some  part  of  one  leg  and  of  the  arm  on  the  same  or 
opposite  side,  or,  exceedingly  rarely,  both  arms  or  both  legs, 
hang  perfectly  limp  and  flaccid.  The  paralyzed  part  offers  ncv 
resistance  to  movement  in  any  direction ;  the  superficial  and 
tendon  reflexes  are  very  much  diminished  or  entirely  absent ; 
the  part  is  apt  to  be  colder  than  the  adjacent  parts.' 

In  by  far  the  greater  number  of  cases,  the  child  feels  well, 
and  there  is  no  febrile  disturbance,  or  other  evidence  of  sick- 
ness. In  a  fair  minority  of  cases,  there  will  be,  for  a  few  days 
preceding,  or  the  first  few  days  of  the  attack,  mild  febrile  dis- 
turbance and  irritability ;  occasionally  the  attack  is  ushered  in 
by  a  distinct  convulsion.     I  have  never  seen  a  case  of  polyo- 


698  THE  DISEASES  OF  CHILDREN. 

myelitis  commence  with,  or  accompanied  by,  high  temperature, 
except  when  occurring  in  the  course  of  some  acute  disease. 

In  a  few  days,  there  will  be  some  improvement  in  the  extent 
of  the  paralysis ;  that  is,  some  of  the  muscles  that  are  paralyzed 
at  the  onset,  regain  the  power  of  motion.  After  the  first  few 
days,  the  paralysis  remains  stationary;  there  is  no  tendency  to 
extension  from  one  part  of  the  cord  to  another.  Very  soon 
the  paralyzed  muscles  begin  to  atrophy  ;  this  process  continues 
for  some  considerable  time,  and  then  remains  stationary.  Aft- 
er a  time,  contracture  in  the  muscles  opposed  to  those  para- 
lyzed begins  to  appear  ;  for  instance,  if  flexor  muscles  are  para- 
lyzed, the  extensors  opposed  to  those  flexors  will  begin  to 
shorten  and  become  contracted;  this  contracture  is  due,  in  a 
great  measure,  to  the  position  in  which  the  member  is  almost 
constantly  kept.  From  these  contractures  in  these  cases,  a 
large  percentage  of  the  various  forms  of  acquired  talipes  and 
other  deformities  result.  The  paralyzed  portion,  after  the  first 
week  or  so,  is  always  colder  than  the  adjacent  part ;  there  are 
no  marked  sensory  disturbances. 

Diagnosis. — This  is  so  distinctly  a  focal  lesion  that  we  often 
find  the  paralysis  restricted  to  one  set  of  muscles.  There  is 
very  little  doubt  as  to  the  diagnosis,  after  the  paralysis  appears. 
In  those  cases  where  there  is  febrile  disturbance  preceding  the 
attack,  polyomyelitis  will  almost  never  be  thought  of  until  the 
occurrence  of  the  paralysis. 

The  absence  of  any  evidence  of  cerebral  disturbance,  the 
sudden  onset  of  the  complete  paralysis,  confined  to  individual 
or  contiguous  groups  of  muscles,  without  sensory  symptoms, 
fully  determines  the  nature  of  the  case.  The  bladder  and  rec- 
tal functions  are  never  permanently  interfered  with  ;  they  may 
be  for  three  or  four  days. 

Prognosis. — This  disease,  except  in  the  few  cases  I  have  des- 
ignated as  functional,  never  tends  to  recovery.  It  does  not  in- 
terfere in  any  way  with  the  general  health.  The  bone  develop- 
ment in  the  paralyzed  member  is  apt  to  be  retarded.  No 
function  of  the  body  outside  the  affected  part  seems  to  suffer 
in  the  least,  except  in  very  rare  cases,  right  at  the  onset ;  there 
is  no  fear  of  a  fatal  termination.  The  child  will  grow  up  unable 
to  use  the  certain  set  of  muscles  and  with  some  deformity.  I 
must  be  excused  for  occupying  a  little  extra  space  here.  The 
parents  will  be  told  that  the  child  will  outgrow  the  trouble — to 
rub  the  muscles,  to  procure  a  battery  and  use  electricity,  to  go 
to  different  baths,  and  a  variety  of  things.  The  parents  them- 
selves will  go  from  one  doctor  to  another,  looking  for  those  who 
will  promise  a  cure  in  the  shortest  time.  The  lack  of  interest, 
the  inclination  to  avoid  painstaking  details,  and  the  feeling  of 


ANTERIOR  POLTOMTELITIS.  699 

not  wanting  to  bother,  on  the  part  of  the  doctor,  combined 
with  impatience,  and  sometimes,  also,  lack  of  interest,  the 
want  of  confidence  in  doctors,  and  the  desire  to  have  the  job 
done  as  cheaply  as  possible,  on  the  part  of  the  parent,  are 
directly  chargeable  with  more  deformities  than  the  disease  itself. 

It  is  my  uniform  habit  to  say  to  the  parent :  "  This  case,  if  it 
is  to  be  cured,  must  be  under  a  systematic  line  of  treatment, 
directed  by  one  competent  physician,  who  is  willing  to  take  the 
time  and  bother  for  a  period  of  from  three  to  five  or  six  years. 
The  treatment  will,  of  necessity,  be  expensive,  and  you  will  be 
importuned  and  exhorted  to  try  a  hundred  other  things  ;  you 
will,  time  and  again,  get  discouraged  because  improvement  is 
so  slow  ;  but  on  this  line  is  a  possible  cure,  and  on  the  other, 
that  of  changing  from  one  to  another  frequently,  there  is  no 
possibility  of  a  cure." 

In  my  own  experience  the  results  have  averaged  better  with 
the  cases  coming  to  my  clinics,  than  in  private  practice,  owing 
to  the  fact,  I  am  sure,  that  they  will  stick  to  a  line  of  treat- 
ment, while  in  the  wealthier  families  there  is  a  constant  tendency 
to  change. 

Treatment. — Always  examine  the  eyes,  for  refractive  trou- 
bles and  heterophorea  ;  the  nasal  passage,  the  throat,  the  gums, 
the  chest  and  the  abdomen,  the  genitals  and  the  rectum.  Re- 
move any  possible  source  of  irritation  at  once.  As  to  remedies, 
I  have  never  been  able  to  see  any  results  from  their  adminis- 
tration internally,  except  in  those  of  tubercular,  strumous  and 
syphilitic  origin. 

In  the  tubercular,  guacuin  is,  I  believe,  indicated  in  a  large 
percentage  of  them,  and  I  am  satisfied  that  I  have  seen  posi- 
tive results  from  its  use.  I  have  found  marked  indications  for 
other  remedies  in  a  few  cases,  and  had  good  results  follow  their 
administration. 

In  strumous  cases,  the  remedy  must  be  carefully  selected, 
on  the  line  of  totality,  and  almost  any  remedy  may  be  found 
to  be  indicated. 

In  the  syphilitic  cases,  kaliiod.  is  as  yet  my  chief  remedy.  I 
begin  with  the  3X,  and  if  no  results  are  apparent  in  two  weeks, 
I  give  the  2x,  and  in  some  cases,  not  many,  have  found  that  I 
did  not  obtain  results  till  I  had  increased  the  dose  to  five  grains 
three  or  four  times  a  day. 

The  general  nutrition  must  be  carefully  attended  to.  Keep 
the  child  well  nourished  ;  good  air  and  plenty  of  it  is  impor- 
tant ;  keep  the  patient  out  doors  as  much  as  possible. 

Use  mechanical  appliances  to  overcome  the  deformities;  do 
not  operate  for  talipes  until  the  paralyzed  muscles  have  com- 
menced to  respond  to  the  will. 


700  THE  DISEASES  OF  CHILDREN. 

Electricity  I  have  not  found  of  any  avail  in  removing  the 
lesion  in  the  cornua.  It  is  of  great  service  in  the  treatment  of 
the  paralyzed  muscles. 

Hot  baths,  regular  daily  massage,  inunctions  of  various 
kinds,  passive  exercise,  and  nerve  vibration  comprises  the  line 
of  treatment. 

Nerve  vibration  has  seemed  to  do  more  toward  restoring 
function  to  the  anterior  cornu,  than  any  other  one  thing.  I 
apply  it  daily  for  some  weeks,  then  rest  from  it  entirely  for 
three  or  four  weeks.  It  should  always  be  used  daily,  when 
used  at  all.  The  effect  is  better  when  used  in  periods,  with 
periods  of  cessation.  It  should  be  continued  throughout  the 
entire  treatment.  Apply  the  hammer  over  the  root  nerves  of 
the  diseased  cornu,  also  over  the  spinous  process,  also  over  the 
motor  nerve  point  of  the  paralyzed  muscles.  Apply  at  as 
near  the  same  time  each  day  as  possible,  and  in  the  same  or- 
der from  point  to  point ;  hold  the  hammer  on  each  point  about 
two  minutes. 

Beside  the  general  hot  baths,  I  have  a  bucket  made  suffi- 
ciently large  for  the  foot  to  stand  flat  on  the  bottom,  and  high 
enough  to  immerse  the  entire  leg,  if  the  paralysis  is  in  the  leg; 
fill  this  with  water  at  ioo°  Fahr.,  have  the  patient  stand  with 
the  paralyzed  leg  in  this,  then  slowly  pour  in  hot  water,  taking 
pains  not  to  have  it  strike  the  leg,  until  the  temperature  of  the 
water  is  103°  Fahr.,  keep  it  at  this  point  ten  minutes.  In  case 
it  is  the  arm  that  is  paralyzed,  have  a  vessel  made  of  proper 
dimensions  for  the  arm  and  use  it  in  the  same  way.  I  fre- 
quently give  this  kind  of  a  local  bath  twice  a  day,  following  it 
with  brisk  rubbing  with  a  coarse  towel. 

Other  points  in  the  treatment  will  be  found  under  the  gen- 
eral treatment  of  paralysis. 

Spinal  Hemorrhage  is  occasionally  found  in  the  new-born, 
usually  in  the  membrane  ;  the  paralysis  is  of  the  flaccid  variety, 
and  there  is  a  tendency  to  spontaneous  recovery  from  absorp- 
tion of  the  clot.  In  a  few  cases,  on  account  of  the  pressure 
and  non-absorption  of  the  clot,  a  secondary  descending  degen- 
eration follows.  The  diagnosis  is  made  by  the  distribution  of 
the  paralysis  and  the  absence  of  cerebral  symptoms. 

Symptoms. — The  sudden  onset  of  a  paraplegia,  accompanied 
with  evidence  of  pain,  and,  if  the  child  be  old  enough  to  ex- 
plain its  sensations,  a  girdle  feeling  about  the  body,  indicates 
a  hemorrhage  in  the  cord  or  membranes.  There  will  be  par- 
esthesias, the  tendon  reflexes  will  be  diminished  or  absent,  the 
cutaneous  reflexes  diminished  or  lost. 

Prognosis. — There  will  be  in  most  cases  a  partial  recovery  very 


PRIMARY  LATERAL  SCLEROSIS.  701 

soon,  and  often  a  nearly  complete  spontaneous  recovery  in  a 
few  weeks,  that  is,  unless  the  hemorrhage  occurs  in  conjunction 
with  some  chronic  disease  of  the  spinal  column,  or  of  the  cord 
or  membranes  ;  even  in  these  cases  there  is  likely  to  be  a  par- 
tial recovery, 

Treatment. — The  treatment  consists  in  quiet,  the  best  sanitary 
and  hygienic  surroundings,  and  attention  to  the  special  nutri- 
tion of  the  paralyzed  muscles.  The  remedies  that  I  have  used 
and  that  have  seemed  to  be  of  value  are :  Aconite  30c,  and 
arnica  30c. 

Primary  Lateral  Sclerosis  is  known  also  as  Spasmodic 
Spinal  Paralysis  and  as  Spastic  Paraplegia. 

It  seems  sometimes  to  be  congenital,  and  often  appears  be- 
fore the  third  year,  but  may  appear  at  any  age.  The  causes 
have  never  been  determined,  so  far  as  I  am  aware. 

Symptoms. — In  a  large  majority  of  the  cases  the  first  symptoms 
appear  in  infancy.  The  first  thing  that  is  noticed  is  that  the 
child's  legs  appear  stiff ;  when  lying  down  it  will  move  them 
about,  but  is  unable  to  stand  on  them.  The  child  learns  to 
walk  very  tardily,  and  is  not  firm  on  its  feet ;  any  attempt  to 
use  the  legs  increases  the  stiffness.  The  legs  slowly  but  grad- 
ually become  weaker  and  weaker,  until  they  become  useless. 
Now,  in  attempting  to  stand,  the  legs  become  rigid,  the  balls  of 
the  feet  rest  on  the  ground,  but  the  heels  are  raised  up,  the  toes 
are  inclined  to  cross  each  other;  the  feet  and  legs,  too,  become 
crossed  ;  there  is  no  pain  and  no  fever ;  the  joints  immediately 
appear  stiffened  if  handled  ;  there  is  no  tremor.  If  a  joint  be 
forcibly  bent — for  instance,  the  leg  flexed  on  the  thigh,  which 
causes  no  pain — it  will  immediately  straighten  out  as  though 
worked  by  a  spring.  There  are  rarely  any  trophic  disturbances. 
The  tendon  reflexes  are  exaggerated.  The  rectal  and  bladder 
sphincters  remain  intact.  The  rigidity  remains  during  sleep. 
The  rigidity  and  inability  to  control  or  coordinate  movements, 
and  all  symptoms  increase  steadily  and  slowly  to  a  point,  then 
remain  stationary.     This  disease  does  not  tend  to  death. 

The  mind  in  many  cases  is  as  bright  and  clear  as  in  other 
persons  of  the  same  age.  In  a  few  instances  there  is  a  lowered 
grade  of  mentality,  but  I  believe  not  due  to  the  disease,  but  to 
-concomitant  trouble. 

Treatment. — The  only  treatment  that  promises  anything,  so 
far  as  I  know,  is  cold  to  the  spine  and  legs,  nerve  vibration  and 
spinal  extension. 

I  apply  cold  douches  to  the  spine  and  legs  daily,  observing 
with  care  that  the  patient  does  not  remain  chilled  for  any 
length  of  time  following.     Apply  spinal  extension  by  means  of 


702  THE  DISEASES  OF  CHILDREN. 

Sayer's  apparatus  on  alternate  days,  keeping  the  patient  sus- 
pended from  fifteen  to  sixty  seconds ;  nerve  vibration,  by  ap- 
plying the  hammer  over  all  the  spinous  processes  and  the  nerve 
roots  on  each  side  of  the  spine,  daily,  a  half  minute  at  each  point. 

Hypertrophic  Paralysis,  Pseudo. — This  is  a  rare  disease 
in  this  country,  but  is  met  with  occasionally.  It  commences 
in  early  life,  usually  before  the  second  year,  but  occasionally 
not  until  the  second  or  ninth  year.  It  runs  a  slow,  steady 
course  of  from  ten  to  twelve  years  commonly.  Death  is  most 
frequently  the  result  of  implication  of  the  respiratory  muscles; 
the  immediate  cause  is  quite  frequently  some  form  of  bronchitis. 

Symptoms. — The  earliest  symptoms  are  weakness  of  the  legs, 
soon  accompanied  with  a  tendency,  when  standing,  to  spread 
the  feet  far  apart ;  later  to  throw  the  shoulders  backward,  curv- 
ing the  spine  backward  very  markedly.  This  is  an  effort  to 
keep  the  center  of  gravity  of  the  body  back  of  the  point  at 
which  the  feet  touch  the  ground  ;  this  is  essential,  in  order  to 
preserve  the  equilibrium.  In  rising  from  a  sitting  posture  or 
from  stooping,  the  patient  puts  his  hands  on  the  knees  to  assist 
in  raising  the  trunk.  In  an  advanced  stage,  the  patient  can 
only  raise  himself  from  a  lying  position  by  first,  with  the  face 
downward,  raising  himself  on  his  hands  spread  wide  apart,  then 
slowly  drawing  one  foot  at  a  time  forward,  kept  wide  apart,  till 
the  feet  and  hands  are  fairly  close  together  (the  patient  in  this 
position  is  on  all  fours,  that  is,  both  feet  and  both  hands  are 
on  the  floor  and  the  arms  and  legs  straight);  then,  by  putting 
first  one,  then  the  other,  hand  on  the  knee  and  raising  the 
trunk,  by  the  aid  of  the  arms,  to  a  perpendicular.  In  nearly 
every  case,  at  an  early  stage,  the  muscles  of  the  calf  of  both 
legs  begin  to  develop  and  become  large  and  hard  ;  they  are  apt 
to  become  enormously  developed,  as  do  also  the  glutei  and 
other  muscles.  While  some  of  the  muscles  are  becoming 
hypertrophied,  others  are  gradually  paralyzed  and  atrophied. 

The  distribution  of  the  atrophy  and  paralysis,  and  of  the 
hypertrophy,  is  very  uneven  and  irregular. 

The  gait  is  characteristic  ;  it  is  very  awkward,  a  rolling  or 
wabbling  gait ;  something  of  a  duck  walk.  The  feet  are  kept 
wide  apart  and  the  shoulders  thrown  far  back.  Any  extra 
strain  on  the  muscles,  manifestly  increases  the  difficulty  of 
walking.  At  times,  the  patient  has  to  exercise  considerable 
ingenuity  in  order  to  walk  at  all,  and  gets  into  very  ludicrous 
positions  in  attempting  to  walk.  In  the  late  stages,  the  child 
becomes  absolutely  helpless.  There  is  apt  to  be  contracture  of 
some  of  the  muscles,  notably  of  the  posterior  leg  muscles,  caus- 
ing a  true  talipes  equinus. 


PARALTSIS  OF  THE  PORTIO  DURA.  703 

The  mind  is  affected  to  the  point  of  idiocy  in  many  cases, 
but  probably  not  by  this  disease ;  it  is  rather  an  accompani- 
ment produced  by  the  same  inherent  cause,  whatever  that  may 
be.  In  many  cases,  the  mind  is  as  bright  and  clear  as  in  other 
children  of  like  age.    There  is  at  no  time  any  febrile  disturbance. 

Prognosis. — The  prognosis  is  decidedly  bad. 

Treatment. — Various  forms  of  baths,  massage,  and  the  Fara- 
dic  current  have  been  recommended,  and  in  a  few  cases,  it  is 
claimed  the  disease  has  been  arrested.  I  have  never  treated  a  case. 

Paralysis  of  the  Portio  Dura,  or  Facial  Paralysis,  should 
be  specially  noted.  It  may  be  serious  or  of  little  import,  de- 
pending on  its  cause.  This  paralysis  may  be  occasioned  by  a 
lesion  at  any  point  along  the  course  of  the  nerve,  from  its  pe- 
ripheral termination  to  its  origin  in  the  floor  of  the  fourth 
ventricle. 

Causes. — The  peripheral  portions  may  be  injured  by  exposure 
to  severe  cold — a  very  common  cause — by  being  involved  in 
inflammation  of  surrounding  tissues,  by  blows  on  the  face,  or 
at  birth  by  the  forceps  during  labor.  In  the  portion  passing 
through  the  fallopian  canal,  it  may  be  involved  by  caries  of  the 
petrous  bone,  usually  from  otitis,  or  by  fracture  of  the  base  of 
the  skull.  Within  the  brain  we  may  have  as  causes,  tumor, 
hemorrhage,  effusion,  thickening  of  the  membranes,  abscess  or 
exudation. 

Diagnosis. —  In  diagnosticating  this  condition,  you  will  exam- 
ine carefully  in  every  case  as  to  the  presence  of  any  discharge 
from  the  ear,  or  any  indications  of  trouble  in  the  ear;  the  con- 
dition of  the  muscles  of  the  tongue  and  palate,  the  presence  of 
any  collateral  brain  symptoms,  or  of  any  sensory  symptoms. 
Follow  the  anatomical  distributions  of  this  and  other  cranial 
nerves,  that  might  be  implicated,  from  their  source  along  their 
entire  course. 

If  the  paralysis  is  noticed  at  birth  and  is  confined  to  one 
side  of  the  face,  a  comparatively  speedy  recovery  is  almost 
certain. 

If  the  paralysis  is  peripheral,  the  affected  side  of  the  face 
will  be  smooth,  the  eye  will  not  close  or  will  only  partially 
close,  and  when  the  child  laughs  or  cries  the  sound  side  of  the 
face  will  be  drawn  and  wrinkled  naturally,  while  the  paralyzed 
side  will  remain  immobile  ;  the  mouth  will  be  drawn  to  the 
sound  side  ;  the  eye  on  the  sound  side  opens  and  closes  natur- 
ally, that  is,  you  will  notice  that  in  all  things  in  which  the 
muscles  of  the  face  are  called  into  action,  those  on  the  sound 
side  respond,  while  those  on  the  paralyzed  side  remain  passive. 

If   the  paralysis  is  the  result  of   exposure  to  severe  cold, 


704  I' HE  DISEASES  OF  CHILDREN. 

massage  and  electricity  will  almost  invariably  result  in  a  cure 
in  a  few  days  or  weeks.  If  the  result  of  a  blow  on  the  face, 
the  prognosis  will  depend  on  the  extent  of  the  injury.  If 
there  be  a  cut  severing  the  nerve,  not  followed  by  sloughing  or 
ulceration,  you  may  quite  safely  predict  a  speedy  recovery.  If, 
however,  there  is  extensive  sloughing,  ulceration,  or  an  exten- 
sive abscess  should  form,  there  may  be  destruction  of  a  sufficient 
extent  of  the  nerve  to  render  reuniting  impossible. 

If  the  paralysis  is  the  result  of  inflammation  of  the  surround- 
ing tissues,  the  prognosis  depends  entirely  on  the  extent  of  the 
destruction  of  the  tissues.  In  these  cases,  after  the  inflamma- 
tory conditions  are  cured,  the  treatment  of  the  paralysis  is  the 
same  as  for  the  uncomplicated  cases,  the  difference  being  that 
in  the  most  severe  cases  you  cannot  predict  results.  It  is 
sometimes  advisable  to  cut  down  upon  the  nerve,  and  either 
loosen  it  from  adhesions  that  have  formed,  or  take  up  the  two 
ends  of  the  nerve  and  stitch  them  together. 

If  the  lesion  is  in  the  fallopian  tube,  the  muscles  of  the  soft 
palate  will  be  affected,  the  uvula  hanging  to  one  side ;  the  arch 
of  the  palate  will  be  flattened  on  the  same  side  as  the  facial 
paralysis.  There  is  a  tendency  for  the  mouth  to  be  dry,  often 
there  is  some  difficulty  in  swallowing,  and  there  may  be  a 
tendency  for  liquid  to  regurgitate  through  the  nose.  There  is 
frequently  a  tendency  for  food  to  collect  between  the  teeth 
and  the  cheek,  or  difficulties  experienced  in  moving  food  from 
that  side  of  the  mouth  with  the  tongue.  These  symptoms  are 
added  to  the  paralysis  of  the  side  of  the  face.  There  will, 
nearly  always,  be  in  conjunction  an  offensive  discharge  from 
the  ear.  With  this  combination  present  there  is  certainly 
trouble  within  the  tubes,  and  the  prognosis  depends  entirely  on 
that  of  the  producing  disease. 

The  treatment  consists  in  preserving  the  nutrition  and  life  in 
the  paralyzed  muscles,  and  such  as  is  indicated  for  the  cure  of 
the  producing  disease. 

If  the  lesion  is  within  the  cranial  cavity,  there  will  be  disturb- 
ances of  sensibility,  squinting,  deafness,  or  a  hemiplegia  ;  there 
will  be  evidences  of  brain  lesion  affecting  other  nerves  as  well 
as  the  facial. 

A  paralysis  of  the  sensory  branch  of  the  fifth  nerve  is  some- 
times found  in  conjunction  with  that  of  the  facial.  If  the 
affection  is  posterior  to  the  Gasserian  ganglion,  there  will  be 
anesthesia  of  the  side  of  the  face,  but  not  of  the  conjunctiva. 
If  anterior  to  the  ganglion,  there  will  be  anesthesia  of  the  side 
of  the  face,  also  of  the  conjunctiva.  There  will  be  danger  of 
ulceration  of  the  cornea,  and  anesthesia  of  the  anterior  half  of 
the  tongue. 


GENERAL    TREATMENT  OF  PARALYSIS.  705 

Prognosis. — The  prognosis  is  necessarily  that  of  the  intra- 
cranial producing  lesion. 

Treatmc7tt. — The  treatment  consists  in  the  preservation  of 
the  local  muscular  nutrition  and  that  adapted  to  the  intracranial 
lesion. 

The  General  Treatment  of  Paralysis. — The  nutrition 
and  integrity  of  the  paralyzed  muscles  must  be  maintained  as 
far  as  possible,  in  order  that,  when  the  motor  impulse  can  be 
transmitted  from  the  motor  center  in  the  brain  to  the  muscles, 
they  can  respond.  Therefore,  while  the  lesion,  whatever  it 
may  be,  producing  the  paralysis,  is  being  treated,  the  muscles 
themselves  must  receive  their  share  of  attention.  Very  fre- 
quently one  or  the  other  is  neglected.  The  one  most  fre- 
quently neglected  is  the  producing  lesion. 

If  there  be  no  tendency  to  atrophy  other  than  comes  from 
non-use,  thorough  massage  and  kneading  daily,  for  from  half  to 
an  hour  should  be  applied.  It  is  wise  to  have  massage  to  the 
entire  body,  to  assist  in  maintaining  the  general  equilibrium  of 
muscle  tone  and  of  the  circulation.  Some  form  of  oily  sub- 
stance should  be  used  with  the  massage,  such  as  cocoa  butter, 
vaselin,  olive  oil,  and  others. 

Passive  exercise  of  the  muscles  should  be  given  every  day ; 
an  attendant  should,  a  number  of  times  each  day,  gently  move 
the  paralyzed  member  or  members  in  every  direction,  flexing 
and  extending,  adducting  and  abducting,  and  from  time  to 
time  have  the  patient  make  efforts  to  resist  these  movements. 
Stretch  and  relax  every  afTected  muscle  in  the  affected  part. 
If  there  is  a  tendency  to  contracture,  either  from  position,  or 
from  central  irritation,  the  shortening  muscles  must  be  placed 
on  a  stretch,  for  from  fifteen  to  thirty  minutes,  six  or  eight 
times  a  day.  If  this  is  not  sufficient  to  prevent  contraction, 
some  form  of  mechanical  appliance  should  be  devised  for  each 
individual  case.  Where  possible,  the  appliance  should  be  fitted 
with  rubber  bands,  or  what  are  called  rubber  muscles.  While 
it  is  better  not  to  have  the  tension  too  rigid,  it  must  be  strong 
enough  to  keep  the  contracting  muscles  on  a  tension  ;  the  ap- 
paratus should  not,  except  in  rare  cases,  be  worn  constantly. 
It  may  be  worn  for  stated  periods  of  one,  two,  or  three  hours, 
and  from  one  to  three  times  a  day,  depending  on  the  judgment 
of  the  attending  physician,  and  not  at  all  on  that  of  the  patient 
or  friends.  It  is  advisable  to  encourage  the  patient  to  make 
frequent  efforts  to  move  the  paralyzed  muscles  by  their  own 
volition.  Be  careful,  however,  in  doing  this,  not  to  allow  the 
patient  to  become  discouraged  because  it  is  so  long  before  they 
can  succeed. 

D.  C— 45 


706  THE  DISEASES  OF  CHILDREN. 

Electricity  is  an  almost  universal  remedy  for  paralysis.  It 
has  done  much  harm  and  some  good  in  the  hands  of  the  laity, 
quacks,  and  those  physicians  who  will  not  take  the  trouble  to 
familiarize  themselves  with  its  sphere  of  action,  its  indications 
and  contra-indications.  It  should  be  studied  with  the  same 
care  as  any  other  remedy. 

It  has  accomplished  wonders.  It  will  do,  just  as  any  other 
remedy  will,  certain  things  that  nothing  else  will.  Excepting 
where  I  have  suggested  its  use  for  the  special  lesion,  it  should 
not  be  applied  in  any  case  of  organic,  sudden  paralysis  until 
one  or  two  weeks  after  the  onset.  I  almost  invariably  use  both 
the  galvanic  and  the  Faradic  currents.  I  rarely,  almost  never, 
use  the  static  in  the  treatment  of  paralysis. 

Any  of  the  batteries  or  machines  found  in  the  surgical  instru- 
ment houses  will  answer  the  purpose.  It  is  wise  to  use  a  mille- 
ampere  meter  always  with  the  galvanic  current,  but  in  this 
kind  of  work  it  is  not  an  absolute  necessity.  A  twelve-cell 
portable  galvanic  battery  and  a  Faradic  machine,  or  a  combined 
galvanic  and  Faradic  battery,  will  answer  the  purpose.  Of 
course  a  stationary  ofifice  battery,  or  a  more  powerful  portable 
instrument  may,  in  rare  instances,  be  needed. 

I  first  test  the  paralyzed  muscles  with  the  galvanic  current, 
commencing  with  a  very  mild  current,  interrupted  within  the 
metal  circuit,  and  gradually  increase  the  strength  until  the 
interruption  produces  a  spasmodic  motion  in  the  paralyzed 
muscle,  provided  such  result  can  be  obtained  without  too  severe 
pain,  or  the  production  of  cutaneous  electrolysis.  Now,  note 
the  direction  in  which  the  current  has  been  passing,  the  num- 
ber of  milleamperes  or  the  number  of  cells  necessary  to  produce 
the  spasmodic  motion,  then  reverse  the  current  and  test  as  be- 
fore, noting  the  strength  of  current  required  to  produce  the 
same  effect.  In  the  treatment  of  the  paralyzed  muscles,  use 
the  current  in  the  direction  from  which  you  get  action  from 
the  current  of  the  least  strength.  Use  a  current  of  just  suffi- 
cient strength  to  produce  mild  contraction.  Give  it  from  two 
to  three  times  a  week.  Make  each  application,  if  to  individual 
small  muscles,  from  two  to  three  minutes.  If  to  individual 
large  muscles,  from  five  to  seven  minutes;  if  to  an  entire  limb, 
from  fifteen  to  twenty  minutes.  The  pole  nearest  the  center 
may  be  placed  over  the  spine,  or  over  a  nerve  trunk  at  a  point 
where  it  lies  near  the  surface,  and  between  the  paralyzed  part 
and  the  spine  or  head.  The  opposite  pole  is  to  be  applied 
over  the  motor  nerve  points  of  the  paralyzed  muscle.  The 
current  should  be  interrupted  within  the  metal  circuit  from  one 
to  twenty  times  per  minute. 

The  Faradic  current  is  to  be  applied  to  the  paralyzed  muscle 


GENERAL   TREATMENT  OF  PARALYSIS.  707 

for  the  purpose  of  retaining  muscular  nutrition,  retaining 
muscle  habit  of  contracture,  and  exercising  the  muscle.  The 
direction  is,  for  the  most  part,  immaterial.  It  should  be  ap- 
plied directly  to  the  paralyzed  muscle.  It  may  be  by  means 
of  a  foot  bath,  with  one  of  the  poles  dropped  into  the  water 
near  the  foot,  or  a  large  wet  sponge  electrode  may  be  placed 
under  the  feet,  the  other  electrode  being  applied  over  the 
various  parts  of  the  paralyzed  muscle,  particular  attention  being 
paid  to  those  points  causing  marked  contractions  in  the  mus- 
cles. Both  electrodes  may  be  applied  by  the  physician  in  such 
manner  as  to  produce  marked  contractions  at  all  parts  of  every 
affected  muscle.  This  can  be  accomplished  by  applying  the 
electrodes  transversely  through  the  various  muscles,  or  longi- 
tudinally. The  current  should  be  of  sufficient  strength  to  pro- 
duce marked,  but  not  excessively  painful,  contractions  in  the 
paralyzed  muscles.  The  application  should  be  daily  and  from 
fifteen  to  thirty  minutes,  except  where  individual  muscles  only 
are  affected,  then  a  shorter  time,  depending  on  the  size  of  the 
muscle.  Where  there  is  marked  muscular  contracture  that 
does  not  yield  to  mechanical  means  alone,  the  galvanic  current, 
applied  regularly  from  ten  to  twenty  minutes,  over  the  con- 
tracted muscles  without  any  interruptions  in  the  circuit,  may 
be  of  decided  service.  The  Faradic  current,  applied  to  the 
opposing  muscles  strong  enough  to  produce  contractions  in 
them  of  sufificient  force  to  place  the  contracted  muscles  on  a 
stretch,  will  frequently  assist  in  overcoming  contracture. 

In  the  treatment  of  paralysis,  electricity  is  not  beneficial  un- 
less followed  up  thoroughly  and  with  judgment.  The  giving 
of  an  occasional  application  is  useless.  In  those  cases  where 
there  is  atrophy  of  the  paralyzed  muscles,  due  to  central  tro- 
phism, and  where  it  is  impossible  to  get  contractions  from  a 
safe  strength  of  current,  apply  as  strong  a  current  as  can  be 
borne  without  injuring  the  skin,  or  frightening  the  little  patient 
to  a  detrimental  degree. 

In  general,  where  you  cannot  get  a  guide  as  to  the  proper 
direction  in  which  to  run  the  current,  apply  the  negative  at  the 
more  distant  and  the  positive  at  the  nearer  point  toward  the 
spine  or  head.  If  anesthesia  is  present,  the  electrical  brush 
will  frequently  be  of  great  service.  The  application  should  be 
daily  or  on  alternate  days,  and  not  exceed  from  three  to  five 
minutes,  with  a  current  of  sufficient  strength  to  make  the  skin 
pink. 

Where  atrophy  of  the  paralyzed  muscle  is  prominent,  the 
massage,  the  oiling,  and  the  electricity  should  all  be  used,  and 
in  addition,  heat.  My  preference  is  moist  heat.  There  is  no 
end  to  the  variet"  of  baths  prescribed   for  cases  of  paralysis. 


708  THE  DISEASES  OF  CHILDREN. 

Any  of  them  are  useful  if  given  properly.  In  cerebral  paraly- 
ses, heat  treatment  or  hot  baths  are  not  usually  indicated,  and 
many  times  are  positively  dangerous.  Thus,  in  hemorrhage, 
thrombus,  tumor,  or  softening  of  the  brain,  or  if  there  is  a  tend- 
ency to  congestion,  heat  treatment  may,  in  any  hands,  prove 
instantly  fatal,  or  do  irreparable  damage. 

Baths  may  be  local  or  general,  that  is,  applied  to  the  para- 
lyzed parts,  as  recommended  under  polyomyelitis,  or  to  the 
entire  body.  The  object  of  the  heat  treatment  is  to  elevate 
the  body  temperature.  If  the  paralyzed  member  alone  is  given 
the  bath,  its  temperature  must  be  raised  by  the  bath,  if  any 
good  results  are  to  be  obtained.  If  the  bath  is  to  the  entire 
body,  the  body  temperature  must  be  raised.  It  is  my  custom 
to  take  the  temperature  of  the  patient  under  the  tongue  on 
entering  the  bath,  to  regulate  the  temperature  of  the  water,  or 
of  the  steam  or  hot  air  chamber,  and  the  length  of  the  time  of 
the  bath  in  such  manner  that  the  temperature  under  the  tongue 
is  raised  from  one  to  two  degrees.  On  coming  out  of  the  bath, 
the  patient  may  be  allowed  to  lie  in  a  pack  for  a  time,  or  be 
immediately  rubbed  dry  with  a  coarse  towel,  vigorously  used. 
I  am  confining  these  directions  to  paralytics.  Thorough  mas- 
sage may  be  used  immediately  following  the  bath,  or  at  some 
other  time  in  the  day,  depending  on  the  special  condition  of 
the  patient.  In  the  atrophic  cases,  where  the  circulation  is 
markedly  decreased  in  the  paralyzed  muscles,  what  is  known 
as  the  vacuum  treatment,  will  often  be  of  very  great  service. 
An  arm  or  a  leg,  or  both  legs,  or  the  entire  body  from  the  neck 
down  may  be  placed  in  the  receiver.  This  treatment  should 
be  followed  up  daily.  Care  must  be  taken  to  exhaust  the  air 
sufificiently  to  force  the  circulation  into  the  capillaries,  but  not 
to  produce  stasis  in  them. 

In  all  cases  of  paralysis  the  functions  of  the  bladder  and 
bowels  must  be  continuously  and  carefully  looked  after. 
Where  constipation  is  the  direct  result  of  the  producing  lesion, 
and  not  the  fault  of  the  digestive  organs  themselves,  mechani- 
cal means  must  be  used  to  move  the  bowels.  In  these  cases  I 
think  I  have  had  more  satisfactory  results  from  the  internal 
administration  of  ox  gall,  either  alone  or  in  some  combination, 
than  from  any  other  laxative.  A  common  prescription  with, 
me  is: 

B:   Fel.  Bovinum  Ex grrs.  60 

Hydrastia  Mur grs.  3 

Aloes  Aqueous.  Ex grs.  3 

Calabar  Bean.  Tr gtts.  24 

Div.  Capsules 12 

Mx. 


GENERA  L    TREA  THEN T  OF  PA RA  L  TSIS.  709 

One  at  night  is  usually  sufficient  to  cause  a  free  and  easy 
movement  of  the  bowels  each  day,  without  any  appearances  of 
cathartic  action.  Occasionally  it  will  be  found  necessary  for  a 
short  time  to  give  two  or  three  a  day.  Aluminum  30c,  natrum 
nur.  30c,  opium  3x  or  30c,  nux  vom.  3X,  and  other  remedies 
will  sometimes  accomplish  the  result.  I  never  use  the  mechan- 
ical means  when  I  can  obtain  results  from  the  best  selection  of 
a  remedy  I  am  able  to  make.  In  some  cases  I  find  it  neces- 
sary to  use  enemas  in  the  rectum  or  up  into  the  colon. 

Remedies  must  be  selected  to  cover  the  particular  lesion  and  a 
paralysis.  It  is  obviously  impossible  to  indicate  a  list  of  reme- 
dies for  paralysis  in  general.  A  list  that  may  be  indicated  in 
the  various  paralytics,  would  comprise  nearly  the  entire  materia 
fnedica.  My  own  experience  has  been  that  when  I  had  ten  or 
fifteen  remedies  that  I  considered  adapted  to  paralysis,  I  did 
not  affiliate  my  remedies  as  closely,  nor  obtain  as  good  results, 
as  I  do  now.  My  method  of  late  years  has  been  to  first  look 
for  my  indications,  without  considering  the  factor  of  paralysis 
at  all.  I  look  for  a  remedy  that  will  cover  the  symptoms  and 
the  pathology  proximately.  I  use  the  word  proximately  here 
for  the  reason  that  there  are  many  lesions  that  must  be  con- 
sidered as  traumatic  or  accidental,  and  it  is  obviously  impossi- 
ble that  any  remedy  can  be  homeopathic  to  these. 


CHAPTER  VI. 

HEREDITARY   ATAXY. 

In  this  there  is  degeneration  in  several  of  the  columns  of  the 
spinal  cord,  the  posterior  columns  being  most  profoundly  af- 
fected. The  lateral  columns  become  affected  almost  invariably 
in  the  course  of  the  disease. 

The  heredity  is  rarely  direct ;  that  is,  it  is  not  common  for 
the  parents  to  have  had  ataxy,  although  this  does  occur  some- 
times. Dissipation,  syphilis  or  insanity  in  the  parents,  or  any 
of  the  conditions  that  reduce  materially  the  nerve  force  of  the 
parent,  are  likely  to  beget  a  neuropathic  child,  a  child  particu- 
larly susceptible  to  nerve  trouble. 

In  this  particular  form  of  ataxy,  it  is  supposed  that  the 
posterior  and  possibly  the  lateral  columns,  are  defective  at 
birth. 

It  seems  to  be  more  common  in  America  than  in  any  other 
country,  but  even  here  there  are  less  than  seventy  cases  re- 
ported. In  this  country  it  seems  to  be  more  common  in  girls 
than  in  boys.  The  first  evidences  usually  appear  at  about  pu- 
berty, sometimes,  however,  as  early  as  eight  years  of  age  or  as 
late  as  sixteen  years  of  age.  In  some  instances,  several  chil- 
dren in  one  family  are  afflicted.  The  duration  is  from  five  to 
twenty  years. 

Symptoms. — The  early  symptoms  are  a  weakness  of  the  legs, 
soon  followed  by  an  uncertainty  in  their  movements.  The  patient 
loses  the  power  of  making  various  motions  as  he  desires ;  the 
foot,  unless  aided  by  the  eye,  cannot  be  placed  on  a  certain  in- 
tended spot.  The  patient  is  uncertain  as  to  the  position  of  his 
feet  and  legs ;  he  is  unable  to  tell,  at  times,  whether  a  leg  is  in 
the  bed  or  hanging  out,  whether  the  legs  are  crossed  or  not. 
Vertigo  is  likely  to  be  present.  There  is  usually  some  pain, 
but  not  marked.  Within  a  year  from  the  onset  the  knee  jerk 
is  abolished.  The  cutaneous  reflexes  are  likely  to  be  more  or 
less  interfered  with  and  are  apt  to  be  irregular. 

The  disease  is  essentially  a  progressive  one.     There  may  be 

long  periods  in  which  there  is  no  noticeable  change.     In  five 

or  six  years,  symptoms,  similar  to  those  in  the  legs,  appear  in 

the  arms  and  hands ;  the  patient  loses  the  power  of  determin- 

(710) 


HEREDITA RT  ATAXT.  711 

ing,  by  sensation,  the  difference  in  the  shape  of  objects  placed 
in  the  hands :  also  the  power  of  determining,  by  sensation,  dif- 
ferences in  the  weight  of  objects.  Later,  the  patient  loses  the 
control  of  the  tongue,  and  is  unable,  while  perfectly  familiar 
with  words,  to  use  the  tongue  in  a  way  to  articulate  with  any 
certainty.  The  head  may  now  have  an  oscillating  motion,  and 
the  extremities  become  choreic.  In  most  cases,  some  form  of 
talipes  is  developed.  Nystagmus  is  common,  other  eye  trou- 
bles are  rare.  There  is  no  optic  neuritis  or  atrophy.  The 
bladder  and  rectal  conditions  are  not  interfered  with.  There 
are  many  symptoms  occurring  in  occasional  cases,  but  those 
mentioned  are  essential  to  the  disease,  and  are  sufficient  to 
determine  the  diagnosis. 

Prognosis. — The  chances  of  recovery  are  not  good  ;  very  few, 
if  any,  cures  are  reported. 

Treatment. — The  patient  should  be  kept  as  quiet  as  possible, 
free  from  all  excitement,  and  have  very  little  physical  exercise. 
The  environments  should  all  be  of  the  best.  The  hygienic  and 
sanitary  conditions  as  perfect  as  possible. 

Massage  should  not  be  used.  Passive  exercise  is  not  to  be 
given.  The  heat  treatment,  with  just  sufficient  surface  rubbing 
to  get  skin  reaction  ;  great  care,  however,  must  be  used  not  to 
burn  or  scald  the  skin.  The  baths,  if  used,  should  not  be 
oftener  than  twice  a  week.  Electricity  should  not  be  admin- 
istered. 

Spinal  extension,  using  Sayer's  apparatus,  beginning  with 
fifteen  seconds,  gradually  lengthening  the  time  to  two  minutes 
every  alternate  day,  should  be  used  in  every  case.  Nerve  vi- 
bration promises  to  give  results  in  these  cases.  It  should  be 
applied  daily  for  a  number  of  weeks,  with  intermission  of  an 
equal  length  of  time.  The  hammer  should  be  applied  over  the 
entire  soles  of  the  feet,  over  each  tendon  at  the  base  of  the 
toes  on  the  upper  side  of  the  foot,  just  behind  each  malleolus, 
over  the  internal  and  external  saphenous  nerves,  over  the  an- 
terior tibial  at  the  instep,  on  the  popliteal  nerve  in  the  pop- 
liteal space,  over  the  external  popliteal  as  it  passes  over  the 
external  condyle  of  the  femur,  along  the  course  of  the  sciatic 
nerve,  over  the  femoral  nerve  in  the  groin,  and  over  correspond- 
ing points  in  the  hands  and  arms.  I  use  about  two  minutes  on 
the  sole  of  each  foot,  and  one  minute  at  each  of  the  other 
points,  making  every  treatment  as  near  uniform  as  to  time  of 
day  and  order  of  procedure  as  possible. 

While  I  have  had  no  experience  with  this  treatment  in  the 
hereditary  ataxy,  I  have  had  sufficient  experience  with  it  in  the 
ataxy  occurring  in  adults  to  warrant  the  statement  that  it  is  a 
curative  agent  of  great  value  in  ataxy. 


712  THE  DISEASES  OF  CHILDREN. 

Acquired  Locomotor  Ataxy,  it  is  claimed,  occasionally 
occurs  in  children.  While  a  case  has  never  been  presented  to 
me,  the  reports  are  from  men  whose  diagnostic  attainments 
forbid  doubt. 

The  symptoms  would  be  the  same,  except  that  the  progres- 
sion is  less  marked  ;  there  is  likely  to  be  diplopia  early  in  the 
case  and  optic  atrophy  later. 

The  prognosis  and  treatment  would  be  the  same. 


CHAPTER  VII. 

IDIOCY. 

Authors  are  agreed  in  recognizing  idiocy,  imbecility  and 
feeble-mindedness,  as  grades  of  the  same  condition.  There  is 
no  difference  except  in  the  degree  of  mental  development,  the 
idiot  possessing  the  lowest  possible  mentality,  the  imbecile  the 
greater  mentality,  and  the  feeble-minded  approaching  to  that  of 
other  children,  of  like  age  and  advantages,  in  its  reasoning 
powers. 

Causes. — The  cause  is  primarily  a  lack  of  cerebral  develop- 
ment, either  of  all  parts  of  the  brain,  or  of  individual  portions. 
This  lack  of  development  may  be  due  to  prenatal  or  to  post- 
natal influences. 

Insanity,  hysteria,  alcoholism,  great  excess  in  the  use  of 
tobacco,  opium,  chloral,  or  other  drugs,  organic  nerve  disorders 
of  the  more  profound  type,  syphilis,  tuberculosis,  great  dissipa- 
tion in  social  or  business  life,  constant  criminal  life,  and  pro- 
longed and  excessive  sexual  dissipation  in  the  parent  or  parents, 
without  doubt  tend  to  arrest  regular  cerebral  development. 
Long-lasting  labor,  by  keeping  the  head  compressed  unduly, 
causes  many  babies  to  be  born  with  suspended  animation. 
Statistics  show  that  a  large  percentage  of  those  mentally  defec- 
tive, had  suspended  animation  at  the  time  of  birth.  The 
general  health  of  the  mother,  any  violent  emotion  or  profound 
and  protracted  grief  during  gestation,  may  affect  the  brain  de- 
velopment of  the  child. 

Cerebral  and  meningeal  hemorrhages,  thrombus  or  embolism, 
occurring  either  at  birth  or  subsequently,  may  cause  an  arrest 
of  development.  Cerebritis,  and  cerebral  meningitis  in  infancy, 
or  frequently  repeated  and  severe  convulsions,  are  fruitful 
sources  of  irregular  and  defective  development. 

Any  disease  of  the  brain  that  produces  pressure  or  serious 
disorders  of  the  circulation  of  the  brain,  may  cause  defective 
development. 

Irritation  of  the  genital  organs,  either  from  anatomical  malfor- 
mations, or  from  masturbation  in  either  sex,  play  a  not  insig- 
nificant part  in  producing  imbeciles  and  the  feeble-minded.  To 
cigarette  smoking  a  number  of  cases  are  clearly  due. 

Profound  emotions,  such  as  fright,  sometimes  seem  to  arrest 

(713) 


714  THE  DISEASES  OF  CHILDREN. 

development.  Traumatism  of  the  head  comes  under  the  dis- 
eases of  the  brain  that  may  effect  its  development.  The  inter- 
marriage of  close  relatives  does  not  have  any  influence. 

Many  cases  are  found  where  it  is  impossible  to  form  any  idea 
as  to  the  cause. 

I  shall  not  here  make  any  classification,  other  than  to  call 
attention  to  differences  between  the  congenital  and  the 
acquired. 

In  the  congenital  cases,  there  are  frequently  deformities  of 
the  body  as  well  as  of  the  brain,  while  in  the  acquired  this  is 
very  uncommon.  In  the  congenital  cases,  the  mental  devel- 
opment, if  there  be  any,  is  slow  and  somewhat  regular  from 
birth.  In  the  acquired  cases,  the  history  will  show  that  the 
child,  up  to  a  certain  time,  was  as  bright,  mentally,  as  other 
children  of  the  same  age,  having  like  opportunities  and  envir- 
onments; then  some  accident,  an  attack  of  sickness,  or  of  long- 
continued,  frequently  recurring,  severe  convulsive  attacks,  and 
with  no  mental  development  from  this  date,  or  a  very  slow  de- 
velopment from  this  time. 

In  some  cases  the  child  loses,  during  an  acute  infectious  or 
febrile  disease,  almost  all  mentality,  temporarily  only.  At 
other  times  the  mentality  is  permanently  lost,  so  that  the  child 
has  no  more  mind  than  a  babe.  The  mental  development  may 
progress  slowly  but  steadily  from  the  time  of  its  arrest. 

In  many  instances  there  is  found  an  exceedingly  low  grade 
of  mentality,  a  pronounced  idiocy,  and  yet  great  brightness  is 
shown  in  some  one  direction.  It  is  not  very  rare  to  find  the 
feeble-minded  person,  that  is  far  above  the  average  in  some  one 
thing.  I  have  a  little  patient  of  nine  years  who  has  locality  so 
thoroughly  developed  that,  even  though  a  stranger  in  this  large 
city,  he  will  remember  any  place  or  building  that  he  has  ever 
once  casually  seen.  I  had  a  case,  a  little  girl  of  ten,  with  a 
general  mind  certainly  not  over  two  years,  that  seemed  to  never 
forget  a  date.  One  of  our  greatest  cat  painters  was  an  imbe- 
cile. These  peculiar,  single  precocious  traits  may  lead  in  any 
direction.     Imbeciles  and  idiots  are  also  often  deaf  and  dumb. 

It  is  not  always  an  easy  matter  to  determine  whether  a  child 
is  a  mute,  or  whether  there  is  not  sufficient  intellection  to  give 
evidences  of  hearing  and  to  converse.  I  do  not  intend  to  say 
"that  there  are  many  cases  of  this  kind,  but  occasionally  it  is 
found,  by  prolonged  and  close  scrutiny,  that  the  hearing  is 
fairly  good,  when  for  a  number  of  years  the  family  and  friends, 
and  even  expert  aurists,  as  well  as  neurologists,  have  been  cer- 
tain of  total  deafness.  A  child  deprived  of  sight  and  hearing 
from  birth,  or  at  an  early  age,  may,  from  this  alone,  be  feeble- 
minded. 


iDiocr.  715 

The  feeble-minded  of  all  grades  differ  as  much  in  tempera- 
ment as  sound  people ;  among  them  are  found  the  amiable  and 
the  irritable,  the  cheerful  and  the  morose,  the  tractable  and  the 
stubborn,  the  quiet  and  the  noisy,  the  gentle  and  the  vicious. 

There  may  be  associated  with  the  feeble  mind  hallucinations, 
delusions  and  illusions.  There  may  be  moral  defects  of  nearly 
all  kinds  and  grades. 

Treatment. — Treatment  of  all  grades  of  the  feeble-minded 
imposes  on  the  physician  the  gravest  responsibility.  The  ten- 
dency to  pure  routinism,  and  to  be  perfectly  satisfied  by  furnish- 
ing an  asylum,  is  directly  chargeable  with  preventing  many 
persons  from  becoming  useful  members  of  society.  The  phy- 
sician who  only  casually  looks  at  a  case  of  this  kind  and  does 
not  learn  everything  that  is  to  be  learned  about  the  patient, 
the  hereditary  influences  and  the  environments,  fails  in  his 
duty.  If  he  has  not  the  knowledge,  ability,  time,  or  interest 
essential  to  the  careful  and  thorough  examination,  he  should 
command  the  parents  or  guardians  to  consult  some  one  who 
■can  and  will  care  for  the  case  intelligently.  The  excuse  that 
there  is  no  place  for  them  where  intelligent  treatment  can  be 
had,  is  no  longer  tenable.  There  are  institutions,  both  private 
and  public,  in  various  parts  of  the  country,  under  the  care  of 
reliable,  educated,  intelligent  and  enthusiastic  physicians. 

The  first  element  in  deciding  on  a  line  of  treatment  is,  to  de- 
termine whether  congenital  or  acquired,  and  the  cause.  Is  the 
cause  one  that  is  still  active,  is  still  a  cause  of  interference  of 
development,  a  present  source  of  irritation,  or  has  it  done  the 
damage  and  ceased  to  be  active?  If  there  is  any  present  source 
of  irritation,  or  of  interference  with  the  circulation  of  the  brain, 
or  of  its  nutrition,  or  anything  that  might  possibly  act  in  this 
way,  treatment  should  be  directed  to  its  cure.  If  convulsions, 
try  to  cure  them  ;  if  a  depressed  section  of  bone,  remove  or 
elevate  it ;  if  an  adherent  prepuce,  circumcise.  Whatever  pos- 
sible present  source  of  irritation,  or  interference  with  circula- 
tion or  development  of  the  brain  can  be  found,  I  again  say, 
undertake  to  cure  it. 

The  next  step  in  the  treatment  looks  to  a  perfect  general  nu- 
trition. Proper  food  and  good  air,  hygienic  and  sanitary  sur- 
roundings, and  judicious  physical  exercise,  must  all  have  care- 
ful attention  and  be  intelligently  prescribed.  The  matter  of 
physical  development  is  probably  as  important  as  any  one 
element  of  treatment,  and  usually  receives  almost  no  attention. 

In  the  line  of  remedies,  I  have  found  unmistakable  good  re- 
sults where  some  cachexia  was  present,  or  where  they  were 
prescribed  for  the  cure  or  removal  of  a  present  acting  cause. 
Where  the  only  indication  I  can  find  is  the  feeble,  undeveloped 


716  THE  DISEASES  OF  CHILDREN. 

mind,  there  is  but  one  remedy  that  I  have  found  to  be  of  any 
advantage :  zinc  phosphid.  I  give  it  usually  in  the  2x  or  3X 
trituration,  sometimes  the  ix,  from  three  to  four  doses  per  day, 
and  continue  it  for  months. 

The  next  element  in  treatment  is  education.  The  good  that 
can  be  accomplished  in  this  direction  is  only  just  beginning  to 
be  appreciated.  I  am  astounded  by  results  I  have  seen  in 
some  of  our  institutions  during  the  last  five  years.  I  am 
sorry  to  be  obliged  to  admit  that  results,  that  I  have  said  were 
absolutely  impossible  to  proximate,  have  been  accomplished. 
In  this  connection  the  question  as  to  home  or  institutional 
training  confronts  the  physician  at  once.  The  mother  knows 
that  she  can  train  and  manage  her  child  better  than  any  one 
else.  There  is  in  the  families  of  the  middle  classes,  a  senti- 
mental desire  to  care  for  the  child  at  home.  Among  the  labor- 
ing classes  and  the  poor,  we  find  many  who  are  strongly 
opposed  to  any  hospital  or  asylum  ;  on  the  other  hand,  many 
of  these  classes  are  perfectly  willing  to  allow  the  child  to 
be  taken  care  of  at  a  proper  institution.  The  very  rich  are 
rather  inclined,  so  far  as  my  own  experience  goes,  to  keep 
these  children  in  seclusion  and  provide  a  private  attendant  or 
governess. 

By  far  the  best  plan  is  the  training  in  an  institution,  for  this 
class  of  children.  The  plea  that  association  with  the  feeble- 
minded only  is  injurious,  does  not  hold  in  actual  experience. 
In  an  association  with  others  of  nearly  the  same  mentality, 
everything  about  the  child  is  brought  within  the  range  of  its 
possible  comprehension.  Comprehension  is  the  all  essential  in 
the  training.  There  is  not  the  discouragement  of  nothing  but 
the,  to  them,  incomprehensible.  Much  is  comprehended  by 
association  with  other  like  children,  while  very  little  is  learned 
from  association  with  children  of  ordinary  mental  endowments. 
The  frictional  irritation  of  brighter  children  about,  is  also  an  ele- 
ment in  retarding  good  moral  development.  The  mother 
rarely  uses  anything  approaching  to  even,  smooth,  firm  discipline 
with  this  kind  of  a  child,  no  matter  how  good  the  discipline  over 
her  other  children  may  be. 

A  private  governess  is  usually  not  trained  for  the  manage- 
ment of  this  particular  class  of  pupils,  and  even  if  one  is  se- 
cured, who  has  the  necessary  training,  the  life  soon  becomes  so 
monotonous  that  the  enthusiasm  is  lost,  and  she  cannot  do  the 
best  that  can  be  done  for  her  charge. 

As  to  the  best  method  of  training,  no  specific  directions  can 
be  given.  Each  patient  must  be  studied  individually,  and 
the  training  adapted  to  its  peculiar  needs. 

There  are  a  large  number  of  children  who  belong  to  the 


IDIOCr.  717 

feeble-minded  class,  who  are  only  enough  below  the  average 
child  to  learn  very  slowly  and  laboriously.  They  can  be  trained 
at  home,  under  a  governess,  or  in  the  school.  Care  must, 
however,  be  taken  to  secure  teachers  who  will  exercise  patience 
and  are  willing  to  lead  slowly.  Care  should  also  be  observed 
that  the  child  is  protected,  as  far  as  possible,  from  the  sharp 
shafts  of  ridicule  so  apt  to  come  from  playfellows. 


CHAPTER  VIII. 

INSANITY. 

Insanity  is  not  common  in  children,  but  is  occasionally 
found.  The  percentage  of  the  insane  increases  with  age.  It 
is  very  rare  before  five  years,  less  so  between  five  and  ten,  still 
less  from  ten  to  twenty ;  after  the  twentieth  year  it  increases 
quite  markedly. 

Causes. — The  first  cause  to  be  considered  is  heredity,  direct 
and  indirect.  The  proportion  having  insane  parents  that  are 
afflicted  with  the  same  trouble,  or  direct  heredity,  is  much 
greater  than  in  most  diseases  of  the  nervous  system.  The  va- 
rious diseases  and  habits  prone  to  produce  the  neuropathic 
child,  or  indirect  heredity,  are  fruitful  sources  of  insanity. 
Traumatism,  emotional  shocks,  or  the  various  diseases  that  in- 
terfere with  cerebral  nutrition,  may  cause  it.  Many  cases  are 
the  direct  result  of  reflex  irritation.  In  all  cases,  even  in  quite 
small  children,  the  rectum,  anus  and  genitals  should  be  care- 
fully and  thoroughly  examined.  Masturbation  is  not  as  common 
a  cause  as  many  authors  claim,  but  there  are  many  cases 
directly  chargeable  to  it.  Neither  sex  is  free  from  this  habit, 
although  boys  outnumber  the  girls  by  a  very  large  majority. 
If  this  habit  is  taught  a  very  young  child  by  a  nurse,  an 
attendant,  or  by  older  children,  it  must  and  does  work  great 
harm,  by  its  profound  effect  on  the  only  partly  formed,  sym- 
pathetic nervous  system.  The  entire  vasomotor  system  is 
rendered  permanently  unstable,  and  perfect,  uniform,  well-bal- 
anced nutrition  of  all  parts  of  the  body  is  impossible.  If 
the  habit  be  learned  at  a  later  age,  say  after  the  tenth  year, 
the  harm  is  not  nearly  so  great  ;  the  injury  then  depends  on 
the  frequency  of  the  act,  and  the  duration  of  the  habit.  In 
this  connection  I  must  mention  a  large  number  of  more  or 
less  pronounced  melancholies  where  the  cause  is  not  mastur- 
bation, but  the  obtaining  by  the  young  man  of  the  erro- 
neous information  that  the  habit  is  necessarily  harmful,  no 
matter  how  little  it  may  have  been  practiced.  Hundreds  of 
these  cases  present  themselves  to  the  physician  where,  on  care- 
ful inquiry,  it  is  learned  that  there  has  not  been  a  sufficient 
practice  of  the  habit  to  do  any  possible  harm  ;  but  the  constant 
(718) 


INSANITY.  719 

brooding  over,  and  looking  for  symptonns  has  rendered  life 
unendurable,  and  produced  the  symptoms  described  by  va- 
rious ignorant  or  unprincipled  men  as  the  sure  result  of  the 
habit. 

Training  and  environment  have  much  to  do  with  the  causation 
of  insanity  in  children,  as  well  as  producing  a  predisposition 
to  it  in  adult  life.  Fright  is  one  of  the  frequent  direct  causes. 
The  habit  so  many  parents,  nurses  and  older  people  have  of 
telling  children  frightful  stories,  of  threatening  them  with  the 
black  man,  spooks,  etc.,  etc.,  cannot  be  too  severely  condemned. 
Children  with  organic  disease  of  the  heart  are  particularly 
susceptible  to  injury  from  fright. 

Many  cases  are  the  result  of  the  acute  diseases  of  childhood. 
Aside  from  those  cerebral  diseases  which  are  prone  to  produce 
insanity,  typhoid  fever,  diphtheria,  scarlet  fever  and  rheumatic 
fever  are  the  ones  most  frequently  followed  by  it. 

Puberty  is  a  favorite  time  for  the  appearance  of  many 
diseases.  Insanity  is  no  exception.  The  sexuality  of  both 
male  and  female  is  so  great  a  part,  anatomically  and  physiolog- 
ically, of  the  emotional  element,  and  the  emotions  in  their 
turn  are  so  important  a  factor  in  all  mentality,  that  anything 
pertaining  in  any  way  to  it  can  but  have  a  profound  influence. 
Correct  knowledge  and  a  careful  guard,  mentally  and  physically, 
as  to  sexual  matters  are  therefore  important  in  the  training  of 
boys  and  girls,  when  approaching  puberty. 

Symptoms. — A  peculiar  form  of  insanity  is  not  at  all  uncom- 
mon in  girls  about  puberty.  It  commences  with  a  slight  actual 
indigestion,  and  very  soon  develops  into  a  pronounced  phys- 
ical indigestion.  The  patients  being  fully  convinced  that  they 
can  take  no  food  of  any  kind  into  the  stomach  without  great 
injury,  frequently  imagine,  if  of  a  religious  turn,  that  the 
taking  of  food  is  a  sin.  The  physician  must,  by  a  careful 
examination,  satisfy  himself  thoroughly  that  there  are  no 
physical  conditions  that  can  produce  the  apparent  digestive 
disturbance,  and  then  either  send  the  patient  to  an  institution, 
or  proceed  to  forcibly  feed  him  through  a  stomach  tube, 
if  necessary.  The  physician  must  see  personally  that  a 
sufficient  quantity  of  good  nutrition  is  introduced  into  the 
stomach  regularly,  and  that  the  patient  does  not  of  her  own 
volition,  by  running  the  fingers  down  the  throat  or  otherwise, 
eject  the  food.  If  there  be  no  source  of  irritation  present,  no 
other  treatment  will  be  needed. 

Insanity  in  children  takes  various  forms.  There  may  be  oc- 
casional outbreaks  of  acute  mania  with  perfectly  lucid  and 
healthy  intervals.  It  is  much  more  common,  however,  to 
meet  cases  in  which  there  is  a  perverted  morality.     It  may  be 


720  THE  DISEASES  OF  CHILDREN. 

a  pronounced  egoism,  selfishness  or  ill-temper;  there  may  be 
an  intense  desire  to  see  and  do  cruel  things,  either  to  insects, 
animals  or  to  persons.  There  may  be  a  constant  tendency  to 
theft,  or  to  some  other  special  moral  wrong. 

Diagnosis. — The  diagnosis  must  be  made  by  a  careful  con- 
sideration as  to  whether  the  child's  life  and  acts  are  at  all  in 
harmony  with  its  environments.  That  which  is  insane  in  a 
child  under  certain  environments,  under  others,  may  be  per- 
fectly sane. 

Treatment. — If  there  is  not  a  pronounced  heredity  or  a  suf- 
ficient emotional  shock,  there  is  some  physical  condition  acting 
as  a  producing  cause.  It  is  the  duty  of  the  physician  to  find 
this  cause.  It  may  take  time  and  a  large  amount  of  patience, 
but  it  is  there  and  must  be  discovered. 

The  treatment  of  these  cases  must  first  be  directed  to  the 
cure  of  any  possible  source  or  reflex  irritation,  or  the  removal  of 
any  direct  irritation.  Cerebral  surgery,  while  not  often  called 
for,  may  in  any  case  be  a  source  of  possible  relief,  and  indica- 
tions for  it  must  be  sought  in  every  case. 

The  urine  should  be,  as  in  all  neurotic  cases,  analyzed  quan- 
titatively. It  may  be  found  that  a  simple  chronic  uremia  is 
the  source  of  all  the  trouble,  or  there  may  be  an  exceedingly 
small  percentage  of  phosphoric  acid  excreted.  The  corrections 
of  these  will  alone  cure  some  cases. 

The  moral  treatment,  as  it  is  termed,  is  of  the  greatest  im- 
portance. There  should  always  be  firm,  even,  regular,  kindly 
discipline.  The  child  is  unable  to  control  itself;  it  can  only 
learn  self-control  by  being  controlled,  and  under  no  circumstances 
should  the  child  be  under  the  management  of  any  person 
who  has  not  perfect  self-control.  Harsh  measures  are  un- 
necessary and  harmful.  Asylum  treatment,  unfortunately, 
cannot  always  be  obtained  for  children.  Where  the  parents 
are  able,  the  child  should  always  be  placed  in  charge  of  a  well- 
trained  and  competent  nurse.  If  the  parents  cannot  afford 
this,  the  physician  must  instruct  the  family  again  and  again  as 
to  the  smallest  details  of  management,  and  keep  a  close,  per- 
sonal watch  over  the  case  constantly.  It  is  often  possible  to 
find  a  good,  level-headed,  motherly  woman,  without  children 
of  her  own  at  home,  exceedingly  well  adapted  to  the  care  and 
management  of  an  insane  child,  who  will  take  charge,  at  her 
own  home,  for  a  very  moderate  compensation. 

The  remedies  I  have  found  useful  in  the  insanities  of  children 
are ;  aconite,  ammonium  carb.,  apis  mel.,  arnica,  arsenicum, 
baryta  mur.,  belladonna,  cactus,  calcarea  carb.,  calcarea  phos., 
cantharis,  capsicum,  causticum,  chamo7nilla,  cimicifuga,  cina, 
cuprum,  ferrum  phos.,  gelsetnium,  helleborus,  hepar,  sulph.,  hyos- 


HTSTERIA.  721 

tyamous,  hypericum,  ignatia,  iodium,  kali  curb.,  kaliphos.,  mer- 
curius,  moschus,  nux  vom.,  nux  moschus,  opium  (very  carefully), 
psorinum,  secale,  silicia,  stramonium,  veratrum  album,  vera- 
irum  viride  and  zinc  phos. 

Hysteria. 

Every  physician  is  called  upon  to  treat  cases  of  hysteria  in 
children,  in  both  boys  and  girls,  previous  to  puberty.  While 
there  are  more  cases  in  girls,  there  is  a  much  greater  propor- 
tion of  boys  affected  by  this  disease  than  is  ordinarily  realized. 
Many  cases  are  not  diagnosticated,  simply  because  the  patient 
is  a  boy. 

Causes. — Heredity  plays  an  important  part  in  the  causation 
of  hysteria.  The  transmission  may  be  direct  from  hysteria  in 
the  parent,  which  in  this  disease  is  quite  frequent,  or  indirect, 
one  or  both  parents  having  been  afflicted  with  some  of  the  dis- 
eases, or  addicted  to  habits  that  are  likely  to  produce  neuropathic 
offspring. 

Training  and  education  are  prolific  causes.  If  it  were  possi- 
ble to  have  every  child  judiciously  trained  and  educated,  hys- 
teria would  be  a  rare  disease.  Those  predisposed  would  almost 
never  have  it  develop,  and  others  would  be  cured  before  de- 
velopment. Discipline  should  begin  in  very  early  infancy  ;  a 
new-born  babe  may  be  taught  to  take  its  food  at  regular 
hours,  to  go  to  sleep  and  remain  so  at  and  for  regular  times, 
without  holding,  rocking  or  carrying.  A  young  babe  can 
learn  that,  if  it  cries  on  account  of  pain,  it  is  always  promptly 
attended  to  ;  and  that  when  it  cries  from  disappointment,  or 
simply  because  it  wants  something  different,  the  crying  does 
not  result  in  accomplishing  the  object.  The  young  child  can 
very  soon  be  taught  to  realize  that,  no  matter  how  kind  and 
indulgent  a  parent  may  be,  repeated  asking  or  teasing  never 
does  any  good  ;  that,  when  the  parent  believes  a  thing  is  not 
good,  it  never  comes ;  that  if  a  parent  thinks  a  certain  thing  is 
for  its  benefit,  it  is  invariably  done.  When  *'  Yes,  my  dear," 
and  "  No,  my  dear,"  are  each  spoken  with  the  same  tenderness 
and  in  the  same  tone,  the  mother  is  teaching  and  the  child  is 
learning.  A  parent  should  never  lose  control  of  his  or  her 
temper  in  dealing  with  a  child.  Under  no  circumstances 
should  a  parent  deceive  or  lie  to  a  child.  The  habit  of  tell- 
ing untruths  to  a  child,  of  deceiving  it  in  various  ways,  under 
various  pretexts,  and  of  buying  the  child  to  do  or  refrain 
from  doing  certain  things,  sows  the  seeds  of  hysteria  in  many 
cases.  As  the  child  attains  the  age  of  understanding,  it  should 
be  given  reasons  for  doing  or  refraining  from  doing.  Where 
D.  C— 46 


722  THE  DISEASES  OF  CHILDREN. 

reason  within  the  comprehension  cannot  be  given,  simply 
say  these  things  will  be  explained  when  old  enough  to  under- 
stand. 

The  child  should  be  taught  early  not  to  fear.  This  includes 
an  absolute  prohibition  of  the  pernicious  habit  of  telling  ghost 
or  other  frightening  stories,  and  of  endeavoring  to  obtain 
obedience  through  the  agency  of  fright.  If  the  physician  has 
to  do  anything  that  is  likely  to  hurt  the  child,  it  is  much  bet- 
ter to  tell  the  child  it  will  hurt,  and  endeavor  to  arouse  its 
pride  to  appear  brave,  than  to  lose  its  confidence  by  lying  to  it. 
If  a  child  loses  its  confidence  in  its  parents  and  physician,  how 
can  we  expect  the  child  to  be  true  ? 

Education,  in  matters  of  book  learning,  and  the  develop- 
ment of  the  mental  powers,  is  a  matter  to  be  studied  in  each 
individual  case.  There  is  no  more  fruitful  source  of  hysteria 
in  the  young,  or  of  hysteria  and  chronic  invalidism  in  the  adult, 
than  a  too  rapid  mental  development  during  the  formative 
period  of  life.  If  a  child  happens  to  be  ever  so  little  brighter 
than  the  average — and  whose  child,  unless  it  be  an  idiot,  is 
not  ? — all  the  friends  of  the  family  must  know  it.  Parents  tell 
me  almost  daily  that  they  do  not  teach  their  little  children 
anything,  that  they  try  to  hold  them  back  ;  but  what  is  the 
fact  ?  Every  little  thing  the  child  learns  from  association  is 
commented  on  to  every  one  in  the  child's  presence,  and  every 
little  couplet  must  be  repeated  before  every  one  that  calls.  In 
short,  the  child  must  show  its  every  accomplishment,  and  be 
unduly  praised  for  it.  In  this  way,  for  the  sake  of  praise  and 
adulation,  the  child  is  stimulated  to  make  mental  effort  when  it 
should  be  only  developing  the  physical.  I  do  not  object  to 
encouragement  by  praise,  but  the  praise  should  be  for  such 
things  as  will  help  a  physical  development,  rather  than  the 
mental,  except  in  those  cases  where  the  mental  is  unnaturally 
slow.  The  grade  of  mentality,  in  independent  thinking  and 
reasoning,  of  the  human  race  would,  I  believe,  be  materially 
elevated  if  school  life  began  at  nine  rather  than  six  or  seven 
years  of  age.  Education  should  have  for  its  prime  object  com- 
prehension, not  simply  abstract  memory.  Make  the  brain  a 
reasoning  organ,  not  simply  a  storehouse. 

Every  child  should  have  a  maximum  of  outdoor  life,  exercise 
that  tends  to  develop  every  muscle  in  the  body,  and  plenty  of 
it,  but  avoid  heavy  straining  at  any  time. 

Look  to  the  child's  sleeping-room,  or  to  the  nursery,  and  see 
that  it  is  so  located  as  to  get  a  maximum  of  sunlight  and  air. 
Do  not  let  an  architect  put  these  rooms  in  any  part  of  the 
house,  simply  so  that  it  does  not  interfere  with  the  general 
symmetry.     Do  not  take  the  sunniest  and  airiest  room  in  the 


HTSTERIA.  728 

house  for  a  spare  room,  and  relegate  the  children  to  any  little 
dark  room. 

Imitation  is  the  cause  of  many  hysterias.  From  this  cause 
there  occasionally  occurs  an  epidemic  of  this  disease.  An  epi- 
demic may  run  through  an  institution  or  a  school.  All  of  the 
cases  will  be  of  the  same  kind.  Within  the  same  family,  one 
child  may  imitate  an  actual  disease  of  some  other  member,  or 
one  member  may  have  some  form  of  hysteria,  and  a  child 
afflicted,  in  the  same  form,  by  imitation. 

Rapid  or  severe  changes  in  temperature  seems  to  act  as  a 
cause  at  times. 

Memory  seems  to  play  an  important  role.  A  child  sees  or 
hears  something  that  makes  a  profound  impression,  or  has 
something  happen  to  it,  possibly  an  accident,  the  thought  of 
which  remaining  constantly  in  the  mind,  may  be  the  direct 
cause  of  hysteria  months  or  years  after.  Many  cases  of  sup- 
posed rabies  are  hysterical  and  belong  to  this  class.  There  is 
in  every  person  of  any  mental  endowment,  in  addition  to  the 
ordinary  memory,  or  that  which  enables  us  to  recall  facts  or 
things,  an  unconscious  memory ;  that  is,  many  things  are 
stored  away,  somewhere  in  the  deeper  recesses  of  the  brain,  of 
which  we  are  entirely  unconscious;  these  things  exert  a  far 
wider,  deeper,  profounder  influence  in  our  lives  than  we  can 
possibly  appreciate.  This  memory  will,  as  has  been  clearly 
proved  in  many  cases,  be  the  cause  of  a  hysteria. 

Any  reflex  irritation  may  be  the  cause  of  a  hysteria.  If 
we  exclude  those  cases  from  direct  heredity,  and  those  due  to 
faulty  training  and  education,  there  will  be  very  few  cases  in 
which  some  form  of  reflex  irritation  will  not  be  found  to  be  an 
important  element  in  the  direct  causation.  So  far  as  my  own 
experience  is  concerned,  the  chief  reflex  causes  have  been  in  the 
eye,  the  digestive  tract  and  the  genitals. 

I  have,  however,  found  every  possible  reflex  irritation  to  be 
the  cause  of  hysteria.  It  is  not  infrequent  to  have  hysteria 
follow  or  appear  during  the  convalescence  from  acute  inflam- 
matory or  infectious  diseases.  There  seems  to  be  a  general 
impression  that  the  hysteric  is  necessarily  of  a  yielding,  weak 
nature ;  the  contrary  I  believe  to  be  true.  The  intellectual 
type,  of  fine  sensibilities,  those  of  tenacious  and  positive  opin- 
ions, and  the  energetic  and  impulsive  people,  are  most  suscep- 
tible to  this  disease.  Another  class  who  are  frequently  sub- 
ject to  hysteria  are  those  of  devout  nature.  Chronic  uremia  is 
a  frequent  cause. 

Symptoms. — An  attempt  to  enumerate  the  symptoms  of  hys- 
teria would  mean  the  mention  of  nearly  every  symptom  of 
every   known  disease.     There  may  be  convulsions,  paralysis. 


Y24  THE  DISEASES  OF  CHILDREN. 

contracture,  chorea,  tremor,  ataxy,  anesthesia,  hyperesthesia, 
paresthesia  of  any  character,  pain  of  all  possible  shades  and 
types,  almost  any  form  of  mental  aberration,  and  so  on  through 
the  list. 

At  times  the  symptoms  in  their  totality  will  so  closely  re- 
semble various  diseases  as  to  render  differentiation  quite  diffi- 
cult, occasionally,  indeed,  impossible  for  weeks.  Blindness, 
deafness  and  mutism  are  not  infrequent  in  children.  Abnor- 
mal excretions,  particularly  the  urinary,  are  fairly  common ; 
many  cases  of  nocturnal  disturbances  are  hysterical.  There 
may  be  an  absolute  suppression  of  urine,  or  in  the  cases  ap- 
pearing near  puberty,  there  may  be  so  much  shrewdness  in 
disposing  of  the  urine  that  the  attendant  finds  great  difficulty 
in  detecting  the  passage  of  any  urine,  and  for  a  time  is  con- 
vinced of  an  entire  suppression. 

Even  quite  young  children  will  show  a  great  degree  of 
shrewdness  in  deceiving  those  about.  In  some  instances  the 
deceptions  are  intentional,  and  for  the  deliberate  purpose  of 
obtaining  an  object ;  but  in  the  true  hysteria,  there  is  an  irre- 
sistible impulse  combined  with  a  degree  of  self-deception. 
There  is  always  a  distinct  effort  at  attracting  attention.  This 
is  often  skillfully  cloaked,  but  is  always  discoverable.  Hyster- 
ical symptoms  are  primarily  for  the  audience,  not  for  the 
patient. 

It  occasionally  assumes  the  form  of  a  theriomimicry  —  that 
is,  a  mimicking  of  certain  animals,  either  the  sounds  made  by 
them  or  their  actions.  If  a  hysterical  child  bites,  it  is  more 
likely  to  bite  some  other  person,  but  occasionally  they  bite 
themselves  quite  seriously. 

Night  terrors  may  be  classed  among  the  nocturnal  hysterias. 

We  have  hysterical  talipes  of  various  forms,  also  hysterical 
hip-joint  disease,  and  spinal  curvature. 

We  find  hysterical  anethesias,  where  the  child  can  be  burned 
or  cut  without  the  least  flinching. 

Persistent  somnambulism  is  claimed  by  some  very  high  au- 
thorities to  be  a  form  of  hysteria.  We  recognize,  also,  a  purely 
hysterical  fever;  the  rise  in  temperature  and  concomitant  symp- 
toms may  occur  only  at  night,  or  during  the  day,  lasting  for  a 
short  time  only,  or  the  fever  may  last  several  days.  The  in- 
creased rapidity  of  the  pulse  and  rise  in  temperature  may  be 
slight.  In  some  cases  the  pulse  will  be  uncountable,  and  the 
temperature  may  rise  to  iio°  Fahr.  without  indicating  danger. 

Catalepsy,  ecstasy  and  trance  must,  at  present,  be  considered 
as  forms  of  hysteria.  These  conditions  are  not  common  under 
the  age  of  puberty,  but  are  occasionally  met. 

Epileptic  or   convulsive   seizures   are  frequently  hysterical. 


HTSTERIA.  725 

Hystero-epilepsy  is  now  fully  recognized  as  a  distinct  entity, 
entirely  separate  from  true  epilepsy  or  from  organic  convulsive 
seizure.  It  is  not  always  an  easy  matter  to  differentiate  the 
hysterical  from  the  true  convulsive  seizures.  In  not  a  few  true 
epilepsies  or  convulsive  attacks  of  reflex  origin,  hysterical  con- 
vulsions occur  as  frequently  as  the  true  convulsions. 

Diagnosis. — The  diagnosis  is  of  the  greatest  importance,  as 
the  prognosis  will,  in  many  instances,  depend  on  learning  early 
the  nature  of  the  disease.  Very  many  chronic  invalids,  who  have 
the  sick  habit  so  fully  formed  that  a  cure  is  absolutely  impossible, 
might  have  been  easily  and  quickly  cured  had  the  nature  of  the 
disease  been  discovered  soon  after  its  first  manifestation.  An 
opinion  by  a  physician  of  some  serious  organic  disorder,  espe- 
cially if  confirmed  by  others,  may  so  thoroughly  imbue  the  inner 
consciousness  that  no  influence  can  eradicate  it. 

The  physician  will  require  all  keenness  of  perception,  all 
of  his  shrewdness  as  well  as  judgment,  to  be  at  all  times  cer- 
tain of  his  ground.  He  must  realize  that  children,  especially 
of  the  class  subject  to  hysteria,  have  keen  ears  and  sharp  eyes, 
are  close  observers,  have  quick  perceptions,  and  bright,  shrewd 
intellects.  He  should,  therefore,  be  very  careful  as  to  what  he 
says  or  does  in  their  presence  or  he  may  be  thwarted  in  the 
study  of  the  case. 

The  diagnosis  must  be  made  by  exclusion.  It  is  my  own 
rule  to  first  look  for  disease  other  than  hysteria.  In  fact,  it  is 
a  universal  rule  with  me,  whenever  I  get  an  early  impression  as 
to  the  diagnosis  in  any  case,  to  undertake  to  prove  that  impres- 
sion wrong.  There  is  no  greater  enemy  to  success  from  a 
purely  professional  point  than  instantaneous  or  intuitive  diag- 
nosis. The  physician  who  can  tell  what  is  the  matter  as  soon 
as  he  looks  at  a  patient,  is,  in  a  large  measure,  responsible  for 
the  great  distrust  of  medical  skill  existing  at  this  time  in  the 
minds  of  the  public. 

In  the  psychical  cases,  the  environments  must  be  considered; 
for  instance,  a  child  living  among,  and  constantly  associating 
with  criminals,  is  not  necessarily  insane  or  hysterical,  because 
it  is  very  deceitful,  shrewd,  and  generally  immoral. 

In  differentiating  from  any  organic  disease,  it  will  always  be 
found  that  some  essential  feature  of  the  organic  disease  is  ab- 
sent ;  it  may  be  in  the  mode  of  onset,  previous  history,  the 
course,  or  the  present  symptoms.  To  determine  this  requires 
careful,  close  physical  examination,  and  a  knowledge  of  those 
things  absolutely  essential  to  the  disease  that  is  resembled. 
Thus,  in  a  hystero-epileptic  attack,  there  is  not  that  form  of 
muscle  action  indicative  of  absolute  loss  of  volition,  or  of 
consciousness.     Close  observation  will  show  that  the  various 


726  THE  DISEASES  OF  CHILDREN. 

contractions  are,  at  least  in  part,  directed  by  the  mind  of  the 
patient.  In  the  hysterical  hip-joint  disease,  the  position  of 
the  foot  will  not  be  right ;  the  pain  on  moving  the  joint  in  the 
socket,  will  not  be  produced  under  the  manipulations  that 
must  produce  pain  if  the  joint  is  actually  the  seat  of  the 
disease. 

The  differentiation  between  hysterical  and  other  convulsive 
attacks  is  sometimes  exceedingly  difficult.  The  hysterical  at- 
tack may  resemble  the  Jacksonian  epilepsy  so  closely  as  to 
make  a  diagnosis  impossible  for  weeks,  or  even  months.  There 
is  no  doubt  that  a  certain  percentage  of  the  cures,  following 
operations  for  the  Jacksonian,  are  in  purely  hysterical  cases. 
In  the  hysterical,  there  is  no  collateral  evidence  of  localized 
lesions,  nothing  in  the  history  to  make  a  localized  cerebral  dis- 
order probable.  In  hysterical  attacks,  each  attack  is  usually 
the  result  of  some  emotional  disturbance.  There  is  apt  to  be 
palpitation,  malaise,  choking,  or  bilateral-foot  aura.  The  onset 
is  apt  to  be  gradual ;  the  scream  likely  to  be  during  the  course 
of  the  convulsion.  The  convulsive  actions  are  usually  in  the 
form  of  rigidity  or  struggling  and  throwing  the  limbs  and  head 
about.  The  biting  is  commonly  of  the  lips,  hands,  or  more 
often  of  other  people  and  things.  Micturition  and  defecation 
almost  never  occur.  Talking  is  quite  frequent.  The  duration 
is  frequently  of  for  half  an  hour,  or  for  several  hours.  The  need 
of  restraint  seems  to  be  more  for  the  purpose  of  controlling 
violence  than  of  preventing  accident.  The  termination  may 
be  spontaneous  or  artificial. 

Prognosis. — The  prognosis  in  hysteria  in  children  is,  or  rather 
may  be,  favorable  in  every,  case,  where  it  is  possible  to  secure 
proper  treatment.  There  are  likely  to  be  recurrences  from 
time  to  time. 

Treatment. — The  treatment  may  be  classed  as  preventive 
and  curative.  The  preventive  treatment,  I  think,  is  sufficiently 
indicated  under  the  causes.  The  nervous  child  should  always 
be  kept  from  emotional  influences  as  much  as  possible.  The 
first  step  in  curative  treatment  should  always  depend  on  the 
thorough  and  complete  examination  that  has  been  made.  Any 
and  every  possible  source  or  reflex  irritation  should  be  cured 
or  removed  ;  following  this,  discipline  must  be  maintained,  not 
harsh,  but  firm  and  steady.  The  right  kind  of  sympathy  is 
difficult  to  obtain.  There  is  in  nearly  every  hysteric,  as  a 
motive  for  the  symptoms,  a  craving  for  sympathy.  In  a  very 
large  number  of  cases,  I  am  sure,  the  patient  is  not  conscious 
of  this.  In  many  cases  the  motive  power  is  the  procuring  of  a 
desired  object,  but  these  cases  are  in  the  minority,  I  believe. 
How   to   secure  sympathy  that  will  not  feed  this   abnormal 


HYSTERIA.  727 

craving,  and  at  the  same  time  will  not  cause  the  patient  to  feel 
that  no  one  has  any  interest  in  him  or  her,  is  a  matter  for  care- 
ful consideration  and  tact  in  each  individual  case.  In  many 
instances  it  is  absolutely  necessary,  even  with  quite  small  chil- 
dren, to  take  them  from  home  into  new  environments,  and 
sometimes  even  away  from  their  own  family,  and  place  them 
under  the  care  of  entire  strangers. 

The  confidence  of  the  patient  must  be  secured.  This  is 
often  a  matter  of  some  considerable  time,  and  it  can  never  be 
accomplished  by  deceiving  the  patient,  nor  will  it  usually  come 
from  positive  statements  alone.  The  physician  must  use  the 
psychical  force  of  which  he  is  possessed,  to  influence  and  mold 
the  inner  consciousness  and  thought  of  the  patient.  This  sug- 
gests hypnotism,  a  subject  I  do  not  propose  to  discuss  here. 
I  will  simply  say  that  many  hysterias  have  been  cured  by  it. 

The  inner  consciousness  of  the  patient  must  in  some  way  be 
convinced  that  improvement  is  going  on ;  telling  a  patient  of 
this  kind  that  it  is  all  imagination  is  harmful,  not  beneficial. 
The  physician  must  recognize  and  feel  that  hysteria  is  a  disease, 
as  much  so  as  any  other  ailment,  and  that  the  cure  requires 
study  and  judgment,  as  well  as  tact. 

General  massage,  and  if  the  patient  is  thin  or  anemics,  oil  of 
some  kind  in  conjunction,  will  be  useful  in  many  cases. 

Electricity  is  often  a  valuable  agent.  Central  galvanism  or 
general  faradism  are  usually  the  best,  but  local  treatment  to 
specially  affected  parts  may  be  valuable. 

Baths  of  various  kinds,  hot  or  cold,  may  be  of  service  in  reg- 
ulating the  circulation,  may  assist  in  elimination  and  in  build- 
ing the  tissues,  and  in  this  way  improve  the  nutrition.  Great 
caution  must  be  used  not  to  frighten  children  in  giving  the 
baths,  or  other  forms  of  treatment.  Douches,  shower  baths, 
and  salt  baths  may  be  of  service. 

Much  has  been  said  of  hysterogenic  points  in  hystero- 
cpilepsy.  In  my  experience,  prompt  cessation  of  a  fit  has 
occasionally  followed  from  pressure  on  the  testicles,  the 
ovaries,  or  the  inframammary  regions,  or  over  the  spine,  but 
many  purely  hysterical  cases  are  not  relieved  at  all  by  this 
measure. 

In  many  cases  where  an  aura  travels  up  an  arm  or  leg,  relief 
is  found  by  pressure  over  a  nerve  trunk  with  the  thumb 
or  a  knotted  ligature  before  the  aura  has  passed  that  point. 
Hypodermic  injections  of  water,  or  medicated,  are  often  bene- 
ficial. 

It  will  frequently  be  found  that  it  is  better  not  to  give  too 
much  attention  to  apparent  local  troubles,  rather  make  the 
treatment  general.     The  child's  mind  should  be  directed  into 


728  THE  DISEASES  OF  CHILDREN. 

other  channels,  rather  than  allowed  to  dwell  on  itself  and  its 
ailments. 

It  will  be,  sometimes  advisable  to  give  a  new  direction  to  the 
study,  reading  and  amusement,  even  where  there  seems  to  be 
no  good  reason  other  than  that  the  patient  is  anxious  to  pur- 
sue its  own  selected  line. 

Remedies  in  hysteria  are  to  be  selected  with  great  care,  and 
can  be  given  with  great  confidence,  but  not  if  the  general  man- 
agement of  the  case  is  neglected. 

The  bromides  and  other  narcotics  and  hypnotics  should  never 
be  used,  they  are  positively  harmful.  The  old  fashioned  drug, 
asafetida,  in  crude  doses,  may  in  some  instances  be  of  great 
service.  It  would  be  impossible  to  give  anything  approaching 
a  systematic  guide,  to  the  selection  of  the  indicated  remedy  in 
the  space  at  my  disposal.  There  is  scarcely  a  remedy  in  the 
materia  medica  that  may  not  be  indicated.  The  remedies  that 
have  been  most  commonly  useful  in  my  hands  in  the  hysterias 
of  children  are  :  aconite,  ammonium  carb.,  apis  mel.,  asafetiday 
belladonna,  calcaria  carb.,  calcaria  phos.,  cantharis,  causticum, 
chamomilla,  ciciita,  coniuin,  gelsemium,  hyoscyamus,  ignatia  kali 
phos.,  lycopodium,  magnesia  phos.,  moschus,  nox  moschata,  nux 
vom.,  platinum,  sanguinaria,  sticta  pulmonaria,  stramonium, 
sulph  ur  and  zincum,  phos. 


CHAPTER  IX. 

DISORDERS   OF   SLEEP. 

The  child  must  sleep  plentifully  if  it  is  to  grow  and  develop 
as  it  should.  During  the  first  three  months  it  should  sleep 
from  sixteen  to  eighteen  hours  every  day.  From  this  to  two 
years  of  age  from  fourteen  to  sixteen  hours,  and  then,  to  ten 
years  of  age,  from  ten  to  twelve  hours.  Insistence  on  regular, 
quiet  sleep,  is  of  the  greatest  importance. 

The  habit,  so  common,  of  taking  children  to  places  of  amuse- 
ment, or  out  visiting  in  the  evening  is  very  bad.  The  digestion 
and  nutrition  cannot  but  be  interfered  with.  The  child  should 
always  sleep  alone  and  should  be,  early,  taught  to  go  to  bed 
and  to  sleep  alone  in  spite  of  light  or  ordinary  noises.  If 
proper  care  is  taken  a  child  will  not  waken  from  any  slight 
cause.  The  perfectly  healthy,  well-trained  child  will  sleep  in 
spite  of  unfavorable  environments.  The  sleeping  room  should 
always  have  the  greatest  possible  amount  of  sun  during  the 
day  and  plenty  of  fresh  air  at  night.  If  a  child  does  not  sleep 
soundly  and  well  there  is  something  wrong  either  with  its  phys- 
ical condition  or  its  environments.  I  am  fully  satisfied  the 
wrong  is  more  frequently  in  the  parents  or  nurses,  than  any 
where  else. 

A  parent  will  claim  to  love  a  child  and  at  the  same  time, 
solely  for  self-gratification  and  self-pride,  will,  on  every  possi- 
ble occasion  show  off  all  the  child's  accomplishments  to  every 
one  with  whom  it  comes  in  contact.  Mothers  will  waken  a 
month  old  babe  to  show  some  friend  what  pretty  eyes  it  has. 
Simply  because  they  want  to  attend  a  party  or  go  somewhere, 
for  their  own  pleasure,  parents  will  take  the  child  along  because 
they  do  not  want  to  remain  at  home  and  cannot  leave  the  child 
alone,  and  thus  break  up  the  regular,  habitual  hours  of  sleep. 
Other  parents  will  give  the  entire  charge  of  the  child  to  a  hired 
attendant,  not  taking  any  particular  pains  to  kno^v  whether 
such  attendant  is  competent  or  not. 

Regularity  of  hours  in  going  to  sleep  and  waking  are  of  the 
first  importance.  Habit  is  a  great  master.  If  a  child  is  kept 
fretted  and  worried,  or  excited  in  any  way,  the  greater  part  of 

(729) 


730  THE  DISEASES  OF  CHILDREN- 

the  day,  it  cannot  get  a  good  restful  sleep,  such  as  is  essential 
to  its  well  being  at  night. 

If  the  environments  are  satisfactory  and  sleep  is  interfered 
with,  the  physician  must  find  some  cause,  for  a  cause  always 
exists  other  than  perversity  on  the  part  of  the  child.  Various 
diseases  interfere  with  sleep.  In  such  instances  it  is  simply  an 
accompaniment  and  is  to  be  considered  in  the  treatment  of 
that  disease. 

Restless,  fitful  sleep,  or  wakefulness  is  probably  more  fre- 
quently due  to  digestive  disturbances  than  to  any  other  cause. 
This  may  be  the  result  of  some  immediate  indiscretion  in  diet, 
or  to  regular,  continued  indiscretion. 

Constipation  is  not  at  all  infrequent  in  children,  and  often 
causes  derangement  of  sleep. 

Various  reflex  irritations  will  derange  the  circulation,  inter- 
fere with  normal  digestion  and  nutrition,  or  produce  a  general 
nervousness,  and,  while  not  sufficient  to  produce  tRe  more 
marked  disorders,  will  interfere  with  the  sleep.  In  many  chil- 
dren there  is  a  condition  that  is  best  described  by  the  term 
cerebral  irritation,  a  condition  in  which,  without  any  actual  or 
regular  derangement  of  the  cerebral  circulation,  where  no  name- 
able  disease  entity  can  be  discovered,  the  child  is  unduly  ex- 
citable, nervous,  peevish,  irritable,  has  more  or  less  headache, 
and  is  a  poor  sleeper,  is  subject  to  unpleasant  dreams,  somnam- 
bulism, night  terrors,  or  even  a  mild  form  of  hystero-epilepsy. 
It  would  not  be  justifible  to  diagnosticate  cerebral  irritation  as  an 
entity  unless  the  symptoms  have  existed  for  some  considerable 
time.  In  these  cases  there  is  always  a  findable  cause,  either  in 
the  training,  the  environments,  the  digestive  tract,  or  in  some 
reflex  irritation. 

In  all  cases  make  a  thorough  and  complete  examination. 
Various  defects  in  the  eye,  it  must  be  remembered,  are  always 
to  be  thought  of  when  reflex  irritations  are  mentioned. 

Treatment. — In  the  treatment  of  these  cases,  first  see  that 
the  psychical  and  physical  environments  are  corrected,  so  far 
as  possible,  then  correct  all  possible  sources  of  reflex  irritation 
and  then  prescribe  your  remedies. 

In  selecting  a  remedy  take  into  consideration  all  the  symp- 
toms presented,  not  those  of  sleep  alone.  Never  under  any 
circumstances  use  any  hypnotic  or  narcotic  to  force  sleep. 
Always  bear  in  mind  that  opium  in  any  form  is  not  well  borne 
by  young  children,  and  is  always  dangerous. 

The  remedies  that  have,  in  my  hands  been  most  frequently 
indicated  are:  aconite,  bellado7ina,  calcaria  curb.,  chamomilla, 
coffea  criida,  cypripediuin,  cimicifuga,  gelseniium,  hyoscyamtis, 
lycopodium,  opium  6x  tojoc,  nux  vom.,  and  stramonium. 


DISORDERS  OF  SLEEP.  731 

Night  Terrors  deserve  special  mention.  It  is  important  in 
that  it  indicates,  if  recurring  at  all  frequently,  a  marked  nervous 
irritability  that  may  lead  to  more  serious  disturbance.  It  has, 
and  properly  so,  been  considered  as  belonging  to  the  nocturnal 
hysterias,  and  yet  as  it  seems  often  to  be  the  only  manifestation 
of  trouble,  it  is  accorded  a  distinct  recognition.  It  is  in  some 
cases,  without  doubt,  a  precursor  of  epilepsy  or  of  recurrent 
convulsions,  not  frequently  enough,  however,  to  warrant  a  pre- 
diction of  the  graver  condition  from  this  symptom  alone. 

It  is  occasionally  an  accompaniment  of  cerebral  organic  dis- 
ease. It  may  be  the  result  of  reflex  irritation,  or  of  emotional 
excitement.  It  is  probably  more  frequently  the  result  of 
digestive  or  intestinal  disturbance. 

The  anemic,  scrofulous,  tubercular  and  rachitic  child  is  more 
likely  to  be  subject  to  these  attacks  than  the  strong  and  robust. 
The  child  of  fine,  sensitive,  nervous  organization,  and  the  very 
excitable  and  enthusiastic  child,  even  if  fairly  strong  and 
well-nourished,  may  be  considered  as  predisposed.  Obstruc- 
tion in  the  nasal  passages  from  catarrh  or  foreign  growths, 
obstructions  in  the  throat  from  foreign  growths,  or  enlarged 
tonsils,  are  quite  frequently  causes.  They  usually  begin  be- 
tween the  first  and  second  dentition,  very  rarely  later  than  the 
eighth  year. 

The  attack  is  more  likely  to  come  on  early  in  the  night, 
within  three  or  four  hours  after  going  to  sleep.  The  child 
wakens  screaming  and  showing  every  evidence  of  being  very 
much  frightened,  may  jump  up  in,  or  out  of,  the  bed,  and  try 
to  fight  off  some  imaginary  thing,  or  throw  the  hands  around 
wildly  in  all  directions.  At  times  the  child  will  indicate,  by 
word  or  action,  the  special  cause  for  fright,  but  more  frequently 
it  is  simply  a  general  fright.  The  child  evidently  is  not  con- 
scious of  its  surroundings,  does  not  know  parents  or  friends 
that  may  be  with  it.  In  a  short  time  usually  from  fifteen  to 
twenty  minutes,  it  may  begin  to  recognize  persons  and  objects 
about,  gradually  becomes  calm,  and  then  goes  to  sleep  and  is 
quiet  until  morning.  There  are,  sometimes  more  than  one  at- 
tack in  the  night,  but  this  is  not  frequent.  The  next  morning 
as  a  rule  there  is  no  recollection  of  the  occurrence,  occasionally 
there  is,  although  there  is  a  great  disinclination  to  talk  about  it 
or  to  hear  it  referred  to. 

The  treatment  must  be  first  directed  to  securing  good, 
healthy  surroundings  and  general  quieting  influences.  Any 
and  all  possible  sources  of  reflex  irritation  should  be  removed 
promptly.  Special  attention  to  the  digestive  tract  should  be 
given.  I  believe  more  cases  have  recovered  while  under  my 
care,  from  the  administration  of  pepsin  than  from  any  other 


732  THE  DISEASES  OF  CHILDREN. 

single  line  of  treatment.  It  will  be  frequently  necessary  to 
circumcise  or  to  remove  the  tonsils,  or  some  foreign  growth 
from  the  nose  or  throat.  In  the  anemic  cases  thorough  nour- 
ishment is  the  essential  element  of  treatment. 

My  chief  remedies,  for  the  night  terrors  themselves,  are : 
belladonna,  hyoscyamus,  nux  vom.,  gelsemium,  calcaria  carb., 
kali  phos.,  cicuta  virosa,  ignatia,  santonin  and  stramomium.  I 
never  use  the  bromides  or  opiates  for  these  cases. 


CHAPTER  X. 

HEADACHES   IN   CHILDREN, 

Children  never  have  headache  unless  something  is  the 
matter  with  them.  They  frequently  complain  of  headache  in 
the  way  of  imitation  or  feign  headache  for  the  purpose  of  ob- 
taining sympathy,  or  their  own  way.  It  requires  very  little 
observation  and  acumen  to  detect  these  cases. 

Headache  may  be  an  accompaniment  of  nearly  any  disease, 
acute  or  chronic.  There  is  a  distinct  nervous  headache,  known 
as  a  bilious  headache,  as  megrim  or  migraine.  This  form  is 
recurrent  at  regular  or  irregular  intervals,  and  without  appar- 
ent immediate  cause.  The  pain  is  very  severe,  may  be  present 
on  waking  in  the  morning,  grow  steadily  worse  for  a  time,  and 
then  gradually  or  suddenly  subside,  very  frequently  during 
sleep.  It  may  come  on  at  any  time  of  day,  gradually  grow 
more  severe,  and  then  gradually  or  suddenly  subside.  It  may 
be  unilateral  or  bilateral.  It  may  appear  first  on  one  side  and 
then  on  the  opposite  side,  or  it  may  sometimes  occur  on  one 
side  in  one  attack  and  on  the  opposite  side  in  another  attack. 
Occasionally  the  attacks  will  alternate  on  the  opposite  sides  of 
the  head  regularly.  In  a  large  proportion  of  the  cases  nausea 
and  vomiting  will  be  associated  with  the  pain  at  some  time 
during  the  attack.  In  some  instances  the  pain  subsides  in- 
stantly whenever  emesis  occurs.  In  these  cases  I  can  see  no 
reason  why  emesis  should  not  be  artificially  produced  promptly, 
but  this  is  only  justifiable  in  the  few  cases  of  this  special  type. 

Disorders  of  digestion,  or  any  other  source  of  reflex  irritation 
may  cause  a  tendency  to  frequent  and  more  or  less  severe 
headache. 

The  child  that  is  brought  up  in  an  unnatural,  forced  atmos- 
phere, or  is  kept  too  constantly  in  doors,  or  is  kept  too  clean, 
who  does  not  get  sufficient  good,  pure  out-door  air  and  physical 
exercise,  who  is  a  constant  recipient  of  don'ts,  or  who  Hves  in 
an  irritable,  excitable  atmosphere,  is  likely  to  have  more  or  less 
headache. 

Kindergartens  and  early  school  life  may,  by  causing  too  close 
mental  activity  in  an  unprepared  brain,  be  the  cause  of  more 
or  less  constant  headache.  In  older  children  too  close  confine- 
ment to  study  is  a  common  source  of  headache. 

(733) 


734  THE  DISEASES  OF  CHILDREN. 

In  this  connection  the  eyes  must  be  specially  mentioned,  as 
they  are  the  cause  of  many  of  the  nervous  and  of  all  other  forms 
of  headache.  Uremic  poisoning  is  often  the  cause  of  either  the 
severer  or  milder  form. 

When  called  to  a  case  in  which  headache  is  the  one  main 
symptom,  and  is  of  frequent  occurrence,  examine  carefully  till 
you  find  the  cause  and  then  treat  that.  If,  after  diligent  and 
intelligent  search,  you  are  unable  to  find  any  cause  there  is 
but  one  road  to  a  cure,  and  while  it  requires  very  close  study, 
and  time  it  will  prove  very  satisfactory.  Take  your  materia 
medica  and  find  the  indicated  remedy.  I  purposely  refrain 
from  mentioning  any  special  remedies,  in  this  connection,  for 
the  reason  that  any  predilection  toward  special  headache  rem- 
edies will  interfere  more  with  success  than  it  will  help.  My 
own  plan  is  to  go  to  my  materia  medica,  in  each  case,  as  nearly 
as  possible  without  prejudice  in  favor  of  any  remedy  or  group 
of  remedies. 


CHAPTER  XI. 

CONGESTION   OF  THE   BRAIN. 

Congestion  of  the  brain  is  a  condition  in  which  there  is  an 
increased  quantity  of  blood  in  the  brain  capillaries.  It  is  a 
condition  much  more  frequently  met  with  in  children  than  in 
adults.  This  is  easily  accounted  for  by  the  greater  susceptibil- 
ity of  the  child  to  both  mental  and  physical  impressions,  and 
consequent  greater  liability  to  circulatory  disturbances. 

Congestion  of  the  brain  may  be  a  primary  disturbance,  but 
is  more  often  an  accompaniment  to  other  diseases.  This  is 
especially  true  of  children,  for  disorders,  which  in  the  adult 
produce  no  appreciable  brain  disturbances,  may  cause  grave 
and  alarming  conditions  in  the  child.  As  stated,  congestion  of 
the  brain  is  an  increase  in  the  amount  of  blood  in  the  brain 
capillaries,  and  since  this  capillary  hyperemia  is  the  cause  of 
the  functional  disturbance  of  the  brain,  it  constitutes  the  chief 
pathological  feature  of  cerebral  congestion. 

Congestion  of  the  brain  may  be  active  or  passive.  It  is  ac- 
tive when,  through  arterial  distention  or  dilatation,  brought 
about  by  causes  acting  directly  upon  the  brain,  or  from  those 
operating  directly  upon  the  heart,  arterial  blood  is  rapidly 
flowing  through  the  capillaries.  It  is  passive  when,  by  some 
obstruction  in  the  course  of  the  circulation,  or  when,  on  account 
of  a  feebly  acting  heart,  blood  is  permitted  to  move  but  slowly 
through  the  capillaries,  and  consequently  is  largely  venous. 

The  capillaries  are  not  visible  to  the  naked  eye,  but  viewed 
with  the  microscope,  are  seen  to  be  much  distended,  often  to 
double  their  natural  size.  There  is  a  deeper  tint  to  the  gray 
substance,  and  an  increase  in  the  number  and  size  of  red  points 
on  section  of  the  white  matter.  In  active  congestion,  there  is 
an  excess  of  arterial  blood  in  the  brain  and  its  membranes,  and 
the  arteries  are  distended  and  filled  to  their  minutest  branches. 
In  passive  congestion,  the  veins  and  sinuses  are  engorged  with 
blood.  The  vessels  in  the  membranes  in  active  congestion  are 
bright  red  ;  in  passive  congestion,  they  are  dark,  or  of  a  bluish 
tint.  In  either  condition,  if  the  congestion  continues  long 
enough,  other  changes  take  place.  If  the  capillary  distention 
is  great,  there  may  be  rupture  and  extravasation  over  larger  or 

(735) 


736  THE  DISEASES  OF  CHILDREN. 

smaller  areas,  or  the  distention  may  be  relieved  by  exudation 
of  serum  into  the  pia  mater. 

Symptoms. — The  symptoms  of  active  congestion  of  the  brain 
are  great  dryness  of,  and  heat  in  the  head,  throbbing  of  the 
carotids,  restlessness  and  peevishness,  especially  on  being  dis- 
turbed, and  jerking  and  twitching  of  the  limbs.  There  will  be 
severe  throbbing  pain  in  the  head,  and  if  the  fontanels  are 
still  open,  they  will  be  distended  and  throb  visibly.  In  passive 
congestion,  many  of  the  symptoms  are  the  same  as  those  of 
the  active  form.  The  irritability  on  being  disturbed,  the  stupor, 
and  the  twitching  are  common  to  both  conditions.  In  the  pas- 
sive form,  there  are  sometimes  marked  general  convulsions. 
In  passive  congestion,  the  heat  of  the  surface  of  the  body,  the 
flushed  face  and  the  injected  eyes  are  not  present.  The  sur- 
face may  even  be  cool  or  bathed  in  considerable  perspiration. 
The  throbbing  of  the  fontanels  is  markedly  absent,  and  the 
distention  of  the  same  is  not  noticeable  until  later,  when  serious 
effusion  has  taken  place. 

Etiology. — The  causes  that  produce  active  congestion  of  the 
brain  in  children  are  numerous.  The  circulation  of  the  sensi- 
tive, undeveloped  brain  of  infancy  and  childhood  is  easily  dis- 
turbed. Strong  mental  emotions,  sudden  fright,  great  grief, 
excessive  delight,  and  indiscretions  or  irregularity  of  diet  may 
operate  as  causes  of  cerebral  congestion  in  children.  Heredity 
plays  an  important  part  in  predisposing  children  to  cerebral 
congestion,  more  particularly  the  active  form.  Any  form  of 
dissipation,  hysteria,  insanity,  and  such  diseases  as  tend  to  pro- 
duce neuropathic  children,  tubercular  diseases  especially,  will 
predispose  the  child  to  cerebral  congestion. 

Children  with  active,  precocious  minds  and  large  brains, 
are  strongly  inclined  to  cerebral  congestion  on  slight  provoca- 
tion. Rapid  or  difficult  dentition  may  also  predispose  to  this 
trouble. 

The  various  inflammatory  diseases  and  febrile  affections,  es- 
pecially in  their  first  stages,  are  often  attended  by  severe  con- 
gestion of  the  brain.  The  elevation  of  the  anterior  fontanel,  so 
markedly  characteristic  of  active  congestion  of  the  brain  in  the 
infant,  is  often  unusually  prominent  in  the  first  stages  of  fevers 
and  inflammations,  and  in  such  cases  cerebral  hyperemia  is  ob- 
viously present.  This  fact  leads  to  the  natural  inference  that 
in  the  first  stages  of  the  febrile  and  inflammatory  affections, 
when  brain  symptoms  are  present,  there  is  often  an  actual,  ac- 
tive cerebral  congestion,  and  not  merely  a  functional  disturb- 
ance of  the  brain  through  sympathetic  nervous  connection. 
The  acute  inflammations  of  the  mucous  membranes  are  most 
likely  to  be  attended  by  cerebral  congestion.     Severe  bron- 


CONGESTION  OF  THE  BRAIN.  737 

chitis,  colitis,  enterocolitis,  and  dysentery,  with  a  sudden  onset 
and  intense  febrile  excitement,  are  frequently  accompanied  in 
this  first  stage  by  active  congestion  of  the  brain.  Extra  activ- 
ity of  the  heart  from  any  cause,  functional  or  organic,  may  be 
a  cause  of  active  congestion.  Traumatic  violence,  as  a  blow  or 
a  fall  upon  the  head,  must  not  be  lost  sight  of  as  a  cause  in  this 
affection,  nor  the  exposure  to  excessive  heat,  the  former  being 
a  frequent  cause,  and  the  latter  occasionally  explaining  an 
otherwise  unaccountable  origin. 

The  causes  of  passive  congestion  differ  very  greatly  from 
those  of  the  active  form.  It  is  due  to  an  impediment  in  the 
return  of  blood  from  the  brain,  or  to  a  weak  and  slow  action  of 
the  heart.  Prolonged  and  difficult  labor  will  at  times  result  in 
the  birth  of  an  infant  presenting  the  most  marked  symptoms 
of  passive  congestion  of  the  brain,  such  as  stupor,  twitching  of 
the  limbs,  and  even  convulsions.  This  condition  may  gradu- 
ally disappear,  unless  hemorrhage  be  coincident  with  the 
congestion. 

One  of  the  most  frequent  causes  is  found  in  strumous  or  tu- 
bercular children,  where  enlarged  glands,  by  pressure  on  vena 
innominata,  or  descending  vena  cava,  obstruct  the  return  of 
blood  from  the  brain.  If  a  child  suffering  with  advanced  tuber- 
culosis of  the  bronchial  or  pulmonary  type  exhibits  brain  symp- 
toms, such  as  rolling  of  the  head,  boring  the  head  into  the 
pillow,  with  possibly  slight  irritability  of  the  stomach,  passive 
congestion  is  the  probable  cerebral  condition,  and  in  such  cases 
extremely  enlarged  bronchial  glands  pressing  upon  the  above- 
mentioned  vessels  have  frequently  been  revealed  by  the  au- 
topsy. Whooping  cough,  which  so  often  produces  extravasa- 
tion into  the  conjunctiva,  and  even  under  the  tissues  surround- 
ing the  eye,  may  sufficiently  interfere  with  the  return  circulation 
from  the  brain  as  to  cause  passive  hyperemia.  Malarial  diseases, 
especially  the  intermittent  and  remittent  types,  where  the  cold 
stage  is  profound  and  prolonged,  may  be  attended  by  serious, 
and  occasionally  fatal  congestion  of  the  brain  and  its  membranes. 
School  children  who  are  exceedingly  studious,  and  great  read- 
ers, and  who  take  comparatively  little  physical  exercise,  are  apt 
to  suffer  from  passive  congestion  of  the  brain.  If  the  child 
hangs  with  the  head  down  for  any  considerable  time,  it 
will  have  a  passive  cerebral  hyperemia,  which  is  occasionally 
serious.  It  is  occasionally  the  result  of  an  accidental  pressure 
about  the  neck.  Foul  air  or  noxious  gases  are  often  productive 
of  this  form  of  congestion.  Asphyxiation  is  nearly  always 
accompanied  by  passive  congestion.  Anything  that  interferes 
with  the  free  action  of  the  lungs  and  oxygenation  of  the  blood, 
may  result  in  passive  congestion.  Rheumatism  or  other 
^.  C— 47 


738  THE  DISEASES  OF  CHILDREN. 

diseases  interfering  with  the  heart's  action  so  as  to  diminish  its 
force,  may  cause  passive  congestion.  Active  or  passive  con- 
gestion may  either  of  them  be  the  result  of  toxic  influences. 
Many  drugs  affect  the  cerebral  circulation. 

Prognosis. — The  cause  operating  to  produce  the  congestion, 
the  intensity  of  the  hyperemia,  and  the  promptness  with  which 
the  proper  treatment  is  instituted,  largely  govern  the  prognosis 
in  this  condition.  The  cases  most  frequently  met,  where  the 
causes  are  such  as  excitement,  fatigue,  overheating,  or  indiscre- 
tion in  diet,  readily  respond  to  prompt  and  proper  treatment. 
Where  the  condition  is  secondary  to  other  acute  diseases  or 
constitutional  disturbances,  the  prognosis  of  the  brain  trouble 
depends  upon  that  of  the  producing  disease. 

The  prognosis  in  passive  congestion,  depending  upon  ob- 
struction to  the  circulation  of  the  brain,  will  be  governed  by 
the  possibility  of  the  removal  of  the  obstruction.  In  those 
cases  resulting  from  continuous  mental  activity,  the  prognosis 
may  be  always  favorable.  In  those  cases  resulting  from  foul 
air  and  noxious  gases,  if  coma  is  not  present,  the  prognosis  is 
favorable.  When  caused  by  lung  or  heart  conditions,  the  prog- 
nosis will  be  that  of  those  conditions.  Cerebral  congestions 
resulting  from  overheating,  while  often  cured,  are  always  to  be 
considered  serious. 

If  congestion  of  the  brain  is  not  recognized  and  controlled 
early,  it  is  likely  to  pass  rapidly  on  to  a  more  serious  condition 
of  extravasation  or  effusion,  with  concomitant  coma  and  possi- 
ble death. 

Treatment. — The  principal  object  to  be  accomplished  in  the 
treatment  of  cerebral  congestion  is  the  diminution  of  the 
amount  of  blood  in  the  encephalon.  The  condition  of  the 
bowels  should  be  inquired  into,  and,  if  necessary,  a  full  enema 
of  warm  water  should  be  given,  or  even  a  brisk  saline  laxative. 
Stimulating  applications  should  be  made  to  the  feet,  such  as 
mustard  or  the  hot  foot-bath.  The  child's  feet  and  legs  may 
be  immersed  to  the  hips  in  hot  water  containing  mustard,  al- 
ways using  at  the  same  time  cold  applications  to  the  head,  but 
never  ice.  If  you  have  reason  to  suspect  the  presence  of  undi- 
gested food  in  the  stomach,  do  not  hesitate  to  give  a  quickly 
acting  emetic.  The  application  of  a  moderately  active  mus- 
tard draught  to  the  cervical  spine  may  follow  the  foregoing 
measures  with  advantage,  still  continuing  the  cold  applications 
to  the  head.  These  are  measures  accessory  to  drug  therapeu- 
tics, which  are  of  the  greatest  importance,  and  should  be  made 
use  of  as  early  in  the  case  as  possible.  The  head  and  shoulders 
of  the  child  should  be  slightly  elevated,  and  perfect  quiet  main- 
tained in   all  its  surroundinfjs.     Never  allow  the  child  to  be 


CONGESTION  OF  THE  BRAIN.  739 

carried  about,  or  rocked  in  a  cradle,  or  jolted  or  swayed  back 
and  forth  in  the  lap  of  the  attendant. 

The  medicines  most  often  indicated  in  the  early  stages  of 
this  affection,  and  upon  which  the  greatest  reliance  may  be 
placed,  are  comparatively  few.  Aconite,  belladonna,  gelsemiumy 
and  veratrum  viride  may  be  said  to  constitute  our  chief  and 
almost  whole  drug  resource  in  the  early  treatment  of  this 
disease. 

Aconite. — Early  in  the  case,  great  heat,  dry  skin  ;  full,  strong 
pulse  ;  high  temperature  ;  anxiety  and  restlessness. 

Belladonna. — Intense  restlessness ;  fierce  delirium  or  incohe- 
rent  muttering;  red,  bloated  face;  injected  conjunctiva;  great 
sensitiveness  to  light  and  noise;  throbbing  of  the  carotids 
and  temporal  vessels.  A  perfect  picture  of  extremely  active 
congestion. 

Gelsemium. — Heaviness  of  the  head  ;  dullness  of  mind  and 
perception.     Child  becomes  drowsy,  comatose  and  convulsive. 

Veratrum  viride. — Great  rapidity  of  the  pulse  is  the  leading 
indication  for  this  drug,  and  especially  if  with  this  symptom 
convulsions  threaten  or  are  present.  It  will  be  more  often  in- 
dicated in  cerebral  congestion  than  any  or  all  other  remedies. 
It  should  be  given  low  and  in  frequently  repeated  doses  until 
some  diminution  in  the  pulse  rate  is  observed,  when  the  size 
and  frequency  of  the  dose  maybe  diminished.  I  consider  it  of 
great  importance  when  veratrum  viride  is  being  given  in  appre- 
ciable doses,  that  the  physician  give  it  himself,  and  with  the 
finger  on  the  pulse  of  the  patient,  carefully  watch  its  effect  until 
the  desired  result  is  obtained,  and  the  dose  is  reduced  to  a  safer 
limit. 

The  causes  operating  to  produce  the  congestion  will  often 
govern  the  selection  of  the  drug  as  much  as  the  symptoms  pre- 
sented. Those  cases  due  to  gastric  or  enteric  disturbances  will 
require  such  remedies  as  bryonia,  nux  vomica,  mer cur ius,  Pul- 
satilla, arsenicum,  or  calcarea  carb.  If  caused  by  overheating, 
belladonna,  glonoin  or  veratrum  vir. 

When  the  result  of  a  fall,  blow,  or  concussion,  arnica,  bella- 
donna, bryonia,  Hypericum. 

If  due  to  excitement,  aconite,  belladonna,  ignatia,  chamomilla, 
or  perhaps  bryonia  or  nux  vomica. 

When  complicating  dentition,  aconite,  chamomilla  or 
gelsemium. 

The  disposition  to  congestion  of  the  brain  is  often  controlled 
by  such  remedies  as  calcarea,  hepar,  silicia  and  sulphur. 

The  remedy  par  excellence  for  school  children  who  show  a 
tendency  to  brain  trouble,  is  calcarea  phos. 

When  congestion  is  due  to  a  feebly  acting  heart,  the  drugs 


740  THE  DISEASES  OF  CHILDREN. 

which  will  increase  the  force  of  the  heart,  in  connection  with 
such  as  have  a  general  tonic  action,  will  be  useful.  Among 
them  are  digitalis,  glonoin,  hydrocyanic  acid,  cactus  and  strychnia. 

In  those  cases  of  passive  congestion,  where  the  pressure  of 
growths  or  enlarged  glands  operate  as  causes  of  circulatory- 
obstruction,  help  must  be  found,  if  at  all,  through  the  drugs 
known  to  have  the  power  of  absorbing  such  products,  or  through 
surgical  measures. 

If  congestion  of  the  brain  is  not  relieved  promptly,  especially 
in  acute  attacks,  effusion  or  extravasation  will  take  place,  and 
other  pathological  conditions  supervene,  after  which  congestion 
is  no  longer  the  prominent  condition,  and  the  disease  would 
probably  be  called  by  another  name. 


CHAPTER  XII. 

MENINGITIS. 

Definition. — Meningitis  is  an  inflammation  of  the  covering  of 
the  brain — the  pia  mater — which  may  be  general  or  limited  to 
the  convexity  of  the  brain  or  to  its  base.  It  may  be  traumatic 
in  its  origin,  idiopathic  or  symptomatic  ;  simple  or  tubercular. 
Until  early  in  the  present  century,  all  inflammations  of  the  brain, 
both  acute  and  chronic,  were  included  in  the  general  term  hy- 
drocephalus. The  latter  term  is  now  restricted  to  those  cases 
of  chronic  character,  in  which  there  is  a  gradual  effusion  of  se- 
rous fluid  into  the  ventricles  of  the  brain,  causing  them  to 
become  more  or  less  distended  and  the  head  enlarged — a  true 
dropsy  of  the  brain. 

A  condition  called  ^^ spurious  hydrocephalus''  is  met  with  not 
infrequently  in  connection  with  the  wasting  diseases  of  child- 
hood, especially  during  the  later  stages  of  inflammatory  diar- 
rhea. 

The  symptoms  of  this  form  of  hydrocephalus  are  those  of 
great  exhaustion,  pinched  features,  livid  complexion,  drowsi- 
ness, which  gradually  deepens  into  coma,  rapid  intermittent 
pulse,  irregular,  sighing  respiration,  subnormal  temperature, 
and  sunken  fontanel. 

Simple  Meningitis. — This  form  of  meningeal  inflammation 
may  be  divided,  according  to  its  causes,  into  idiopathic  and 
traumatic — the  former  being  much  more  common  than  the  lat- 
ter. All  forms  of  meningitis  are  more  common  in  childhood 
than  in  adult  life.  It  is  much  more  frequently  met  with  among 
males  than  among  females.  It  is  apt  to  occur  in  the  course  of 
any  and  all  the  acute  febrile  diseases,  such  as  measles,  scarla- 
tina, and  rheumatic  fever.  It  may  occur  as  a  complication  in 
erysipelas  of  the  head  and  face,  or  in  the  course  of  pneumonia 
or  pleuro-pneumonia. 

It  is  common  among  cachectic  subjects,  independently  of 
previous  acute  affections.  Diseases  of  the  ear  and  nose  are 
quite  prone  to  extend  their  baneful  influences  to  the  brain  and 
eventuate  in  acute  simple  meningitis.  Excessive  mental  activ- 
ity at  school  is  undoubtedly  responsible  for  many  cases,  as  is 
prolonged  exposure  to  the  direct  rays  of  the  sun. 

(741) 


742  THE  DISEASES  OF  CHILDREN. 

The  traumatic  variety  is  met  with  after  injuries  of  the  head, 
as  from  blows,  even  when  the  blows  have  not  been  severe 
enough  to  cause  an  external  wound  or  fracture  of  any  of  the 
bones  of  the  skull. 

Simple  idiopathic  meningitis  is  usually  due  to  an  extension 
of  some  inflammatory  process  remote  from  the  brain,  and  is 
therefore,  a  secondary  disease,  the  traumatic  variety  alone  being 
primary. 

In  post-mortem  examinations  of  children  dead  of  meningitis, 
the  brain  is  usually  found  covered  with  a  layer  of  yellowish  or 
green  pus,  and  the  same  kind  of  substance  may  be  found  also  in 
the  ventricles.  For  this  reason  the  disease  is  frequently  known 
as  "suppurative  meningitis," 

In  prolonged  cases — it  sometimes  lasts  a  month — the  pus 
may  be  found  to  extend  down  about  the  cord  in  quantity, 
where  it  will  mostly  appear  on  the  posterior  aspect,  having  evi- 
dently gravitated  to  that  position.  There  is  practically  no  dif- 
ference between  meningitis  of  the  brain  and  that  of  the  cord. 

The  membrane  affected  is  one  and  the  same,  and  disease  of 
the  membranes  of  the  brain  run  with  perfect  facility  along 
those  of  the  cord.  There  is,  therefore,  no  occasion  for  a  sepa- 
rate consideration  of  that  form  of  meningitis  in  which  both 
brain  and  cord  are  involved,  and  known  as  "  cerebro-spinal 
meningitis." 

Symptoms. — The  symptoms  of  meningitis  are  often  indefi- 
nite. Hebetude  or  coma  will  not  infrequently  occur  in  chil- 
dren, seemingly  of  the  most  alarming  nature,  but  which  will 
disappear  in  a  day  or  two,  being  apparently  a  reflex  of  some 
indigestion  or  vasomotor  condition.  Then  again  the  acute 
febrile  affections  of  children,  such  as  the  pulmonary,  enteric 
and  miasmatic  diseases,  and  the  exanthemata  will  produce  grave 
conditions  of  hebetude,  coma  or  delirium,  and  it  will  often  be 
a  matter  of  great  nicety  to  determine  how  much  is  reflex  from 
the  primary  disease,  and  how  much  may  be  due  to  actual  im- 
plication of  the  cerebrum  or  its  membranes. 

The  symptoms  are  apt  to  vary  somewhat  with  the  age  of  the 
child.  In  young  infants  there  is  a  tendency  to  collapse,  rest- 
lessness, swelling  of  the  head,  enlargement  of  the  veins  of  the 
surface,  and  retraction  of  the  neck. 

In  older  children  there  is  apt  to  be  more  fever  and  more  defi- 
nite evidences  of  meningitis  in  headache,  vomiting,  irregularity 
of  pulse,  and  squint. 

Whatever  the  age,  the  face  is  pale  and  pinched,  the  head  is 
retracted,  the  bowels  confined  and  food  is  taken  badly.  Among 
the  early  symptoms  cephalalgia  is  usually  pronounced,  and  is  of 
an  intermittent  character.     This  cephalalgia  may  be  general  or 


SIMPLE  MENINGITIS.  743 

localized  in  some  particular  region  of  the  head,  and  if  the  child 
is  old  enough  to  describe  his  sensations,  it  is  complained  of 
again  and  again ;  if  too  young  to  talk,  the  pain  is  indicated  by- 
cries,  by  application  of  the  hands  to  the  head,  or  by  other  un- 
mistakable signs.  The  intensity  of  the  pain  in  the  head  varies 
greatly  in  different  subjects,  and  in  some  cases  it  may  be  nearly 
absent,  or  it  may  come  on  at  a  later  date.  Insomnia  is  gener- 
ally present  from  the  commencement  of  the  attack.  Delirium 
of  various  grades  of  intensity  is  usually  present,  sometimes  of 
a  mild  and  quiet  type,  mere  loquaciousness ;  at  others  it  is  fu- 
rious, and  attended  with  screams  and  kicks. 

In  some  cases  delirium  is  replaced  by  a  semi-comatose  con- 
dition which  gradually  deepens  into  actual  coma.  Nausea  and 
vomiting,  and  also  convulsions,  either  general  or  local,  may  be 
met  with  in  the  early  stages  of  the  disease,  and  also  as  initial 
symptoms. 

There  is  often  intolerance  of  light  and  loud  sounds,  more  or 
less  general  pyrexia,  with  heat  of  head,  rapid  pulse  and  irregular 
respiration.  The  tongue  is  furred,  and  often  thickly  coated. 
The  bowels  are  constipated. 

As  the  disease  progresses  we  are  pretty  sure  to  have  convul- 
sions or  spasms,  often  of  the  tonic  order,  affecting  the  muscles 
of  the  head  and  neck,  which  are  frequently  drawn  backwards, 
or  one  or  both  arms ;  or  a  condition  of  trismus  may  exist.  The 
eyes  are  sometimes  drawn  upwards,  and  occasionally  inwards. 
The  pupils  may  be  at  first  contracted,  but  later  are  widely  di- 
lated and  insensitive.  Inequality  of  the  pupils  is  quite  com- 
mon. The  conjunctiva  are  often  injected.  The  abdomen  is 
retracted  and  hollow.  Difficulty  of  deglutition  is  frequently  well 
marked  toward  the  end.  As  soon  as  the  stupor  is  pronounced, 
there  is  incontinence  of  feces  and  urine.  The  temperature  is 
at  times  high,  but  subject  to  fluctuations — marked  irregularity 
of  temperature  being  quite  typical.  The  skin  is  generally  hot 
and  dry,  though  occasionally  there  may  be  copious  sweats. 

Prog7iosis. — A  large  percentage  of  deaths  take  place  within 
the  first  week  of  acute  meningitis ;  a  much  smaller  number  sur- 
vive till  the  end  of  the  second  week,  while  a  few  exceptional 
cases  do  not  succumb  till  into  the  fourth  week.  The  disease  is 
one  of  great  gravity  ;  and  while  it  is  difficult  to  say  just  what 
the  percentage  of  recoveries  is,  it  probably  does  not  exceed  ten 
in  a  hundred  cases. 

Diagnosis. — The  differentiation  of  idiopathic  from  tubercular 
meningitis  is  attended  usually  with  much  difficulty. 

The  treatment  of  both  varieties,  however,  is  so  similar,  that 
an  accurate  diagnosis  is  not  altogether  essential. 

The  fact  that  an  inflammation  of  the  meninges  is  present  or 


744  THE  DISEASES  OF  CHILDREN. 

threatened,  is  a  matter  for  the  gravest  consideration.  A  few 
points  will  aid  in  reaching  a  decision  as  to  which  form  we  are 
dealing  with. 

In  the  first  place,  idiopathic  meningitis  is  far  more  rare  than 
tubercular,  the  latter  being,  unfortunately,  all  too  common.  De- 
lirium is  rarely  so  violent  in  tubercular  as  it  may  be  in  simple 
meningitis. 

Retraction  of  the  head  is  also  neither  so  marked  nor  so  fre- 
quent in  the  tubercular  variety. 

The  temperature  is  usually  higher  in  simple  than  in  tuber- 
cular meningitis — rarely  rising  over  103°  Fahr.  in  the  latter 
form.  In  tubercular  meningitis,  the  two  sexes  fall  victims  in 
about  equal  numbers,  while  in  simple  meningitis  two  out  of 
three  cases  are  likely  to  be  males.  In  children  and  infants  re- 
traction of  the  neck  should  always  excite  apprehension,  and 
any  rigidity  of  the  neck  or  pain  in  movement.  The  other  signs 
of  meningitis  must  then  be  sought  for,  such  as  rigidity  of  mus- 
cles elsewhere,  evidence  of  pain  in  the  head,  swelling  of  the 
head,  distention  of  the  veins  of  the  scalp,  vomiting  without  ap- 
parent cause,  retraction  of  the  abdomen,  constipation,  irregu- 
larity of  pulse,  sighing  respiration,  a  tendency  to  reddening  of 
the  skin  after  slight  friction  {tache  ccr^brale),  and  the  state  of 
the  fundus  oculi. 

The  previous  state  of  health  should  be  inquired  into — the 
prior  existence  of  measles,  scarlet  fever,  sore  throat,  earache, 
etc.  In  meningitis  no  one  symptom  is  infallible,  and  the  whole 
group  of  symptoms  will  often  leave  us  in  temporary  doubt. 
The  most  reliable,  however,  are  retracted  head,  fever,  causeless 
vomiting,  irregularity  of  pulse,  and  muscular  rigidity  or 
weakness. 

Treatment. — To  avoid  needless  repetition,  the  reader  is  re- 
ferred for  treatment  to  the  next  section  on  Tubercular  Menin- 
gitis, where  the  whole  subject  of  remedial  measures  will  be 
discussed. 

Tubercular  Meningitis. — Tubercular  or  "  granular"  men- 
ingitis differs  from  simple  or  idiopathic  meningitis  in  having  its 
remote  origin  in  a  general  tuberculous  condition  of  the  subject 
— in  other  words,  it  is  tuberculosis,  plus  meningeal  inflamma- 
tion. Tubercular  meningitis  is  not  an  independent  affection, 
but  constitutes  one  important  phase  of  "  a  many-sided  general 
disease  commonly  known  as  acute  tuberculosis,  and  marked 
anatomically  by  the  presence  of  '  gray  granulations  'within  the 
the  thorax  and  abdomen,  as  well  as  in  the  membranes  of  the 
brain.  In  certain  rare  cases  death  takes  place  from  granular 
meningitis  before  the  anatomical  marks  of  the  general  disease 


TUBERCULAR  MENINGITIS.  745 

have  had  time  to  develop  within  the  chest  or  abdomen.  More  fre- 
quently, however,  the  manifestations  of  the  general  disease  are 
already  developed  in  one  or  other,  or  in  both  of  these  situa- 
tions, at  the  time  that  they  reveal  themselves  also  on  the  side 
of  the  brain.  In  the  latter,  and  by  far  the  most  common  class 
of  cases,  the  symptoms  met  with  will  be  in  part  those  of  the 
general  affection,  and  in  part  (but  in  a  predominant  degree) 
those  due  to  that  implication  of  the  brain  and  its  membranes 
with  which  we  are  specially  concerned."  See  preceding  section 
on  Idiopathic  Meningitis. 

Etiology. — From  what  has  just  been  said,  it  will  be  seen  that 
the  etiology  of  tubercular  meningitis  resolves  itself  into  the 
etiology  of  the  general  disease — acute  tuberculosis — of  which  it 
forms  a  part,  and  the  reader  is  referred  to  the  chapter  on  this 
affection,  where  the  subject  of  etiology  is  fully  discussed. 

Symptoms. — By  some  authors  the  disease  we  are  now 
considering  is  divided  into  different  stages,  each  with  its  own 
peculiar  symptomatology.  But  it  is  only  in  rare  and  typical 
cases  that  such  a  division  can  be  at  all  helpful  in  setting  forth 
a  picture  of  the  disease. 

To  the  experienced  and  watchful  physician  there  are  certain 
prodromal  symptoms  that  in  many  cases  are  sufficiently  pro- 
nounced to  attract  early  attention  to  the  approach  of  serious 
disorder,  and  it  is  in  such  cases,  and  in  such  cases  only,  that  our 
remedies  will  be  found  of  value.  These  early  symptoms  are 
gradual — sometimes  rapid — emaciation,  restlessness,  impaired 
digestion.  At  night  the  child  grinds  his  teeth,  has  night  terrors, 
wakens  frightened,  or  has  strange  fancies  and  delusions.  In 
some  cases  there  is  a  newly-developed  perverseness,  so  that  a 
naturally  tractable  child  becomes  unmanageable  and  willful,  or 
is  irritable  and  peevish ;  in  other  cases,  the  child  becomes  taci- 
turn, sad  and  apathetic,  indisposed  to  play ;  the  appetite  is 
fickle,  with  craving  for  strange  and  unsuitable  things.  One  of 
the  most  characteristic  symptoms  of  this  early  stage  is  when 
the  child  will  waken  with  a  scream,  or  will  sit  up  in  bed  and 
shriek.  Even  now  there  may  be  headache,  though  this  usually 
forms  a  prominent  symptom  later  on  in  the  progress  of  the 
disease.  There  may  be  some  squinting  or  twitching  of  the 
facial  muscles.  Many  or  all  of  these  symptoms  are  often  so 
slight  that  they  pass  unnoticed  till  too  late;  but  all  of  them  are 
significant  and  not  one  of  them  should  be  allowed  to  go  un- 
heeded. 

There  is  often  a  remission  of  symptoms  during  this  early 
stage,  so  that  physicians  and  friends  think  that  the  child  has 
recovered  his  health  ;  but  this  is  generally  delusive,  and  a  little 
later  the  same  symptoms  return  with  increased  violence.  Head- 


746  THE  DISEASES  OF  CHILDREX. 

ache  will  now  be  complained  of,  or  indicated  by  sign  language  ; 
a  convulsion  is  likely  to  occur,  or  the  child  lies  in  a  comatose 
state,  with  pupils  unequally  dilated,  pulse  rapid  and  irregular, 
respirations  sighing,  or  of  the  cheyne-stokes  variety.  The  child 
complains  of  light  and  sound  ;  the  tongue  is  dry,  or  has  a  thick, 
moist  coating,  with  red  edges.  During  sleep  he  occasionally 
utters  a  sharp,  shrill  cry  without  awakening — the  cri  encepha- 
lique — so  characteristic  of  the  disease. 

When  these  symptoms  are  present,  we  have  a  typical  case  of 
tubercular  meningitis  in  the  first  stage.  But  they  are  inclined 
to  remit  and  remit  again,  until  sometimes  weeks  and  even 
months  go  by  before  the  critical  stage  is  reached.  More  often 
the  case  goes  on  gradually  from  bad  to  worse,  unless  the 
nature  of  the  disease  is  early  recognized  and  remedies  are 
brought  to  bear  upon  it.  The  apathy  increases  ;  the  eyes  are 
less  sensitive  to  light ;  the  constipation  is  obstinate. 

After  a  variable  period  the  child  shows  signs  of  disturbances 
of  nerve  centers,  due  to  increased  exudation  and  pressure  at 
the  base  of  the  brain.  This  is  manifested  by  strabismus,  twitch- 
ing of  facial  muscles,  paralysis  or  coma.  If  the  anterior  fonta- 
nel is  still  open,  it  is  found  bulging,  and  the  scalp  covering  it 
is  tense  from  pressure  of  the  effusion  beneath.  The  fever  in 
tubercular  meningitis  is  not  usually  high.  It  may  not  exceed 
ioo°  Fahr.  until  towards  the  fatal  end.  The  pulse  is  often  be- 
low the  normal  in  frequency,  and  in  nearly  all  cases  is  extremely 
irregular.  In  the  latter  stages  of  the  disease,  frequent  and  long- 
continued  convulsive  seizures  are  apt  to  occur,  and  death  may 
take  place  during  or  immediately  after  one  of  these  attacks. 

The  patient  may  take  the  food  which  is  offered  up  to  the 
last,  though  at  other  times,  or  in  other  cases,  there  seems  to  be 
an  actual  inability  to  swallow  it,  even  when  it  is  placed  in  the 
mouth,  owing  to  the  paralysis  of  the  muscles  of  the  tongue  and 
pharynx. 

Inclination  to  remit  in  all  stages  is  a  characteristic  of  the  dis- 
ease. Unequal  dilation  of  pupils  may  be  said  to  be  considered 
a  reliable  symptom  of  beginning  trouble,  and  should  attract 
our  attention  and  call  for  prompt  action.  The  irritation  and 
change  in  temperature,  with  restlessness,  crying  out  in  sleep  and 
sudden  vomiting  without  nausea,  are  constant  symptoms  of  the 
premonitory  stage  and  should  cause  alarm. 

The  irregular  pulse  and  respiration  are  sure  indications  of 
progress.  The  temperature  is  of  very  little  help  in  diagnosis. 
The  coated  tongue  and  offensive  breath  are  not  infallible,  but 
help  to  make  up  the  case. 

Diagnosis. — Usually  the  disease  offers  but  little  difificulty  in 
diagnosis,  especially  after  it  is  well  developed  ;  although  none 


TUBERCULAR  MENINGITIS.  1^1 

of  the  above  symptoms  singly  are  pathognomonic  of  the  dis- 
ease, still  taken  as  a  whole,  considering  age,  antecedents  and 
previous  health,  you  have  a  case  not  easy  to  mistake.  The 
real  trouble  is  in  the  very  early  stages  before  all  symptoms  are 
developed.  Then  it  is  sometimes  difficult  to  say  that  it  is  the 
beginning  of  brain  disease,  and  yet  this  is  the  critical  time  in 
the  disease.  A  failure  to  recognize  the  importance  and  mean- 
ing of  these  symptoms  will  turn  the  case  from  possible  recovery 
and  gratitude  of  friends  to  sorrow  and  death. 

The  diseases  for  which  tubercular  meningitis  is  most  likely  to 
be  mistaken  are  acute  simple  meningitis,  early  stage  of  typhoid 
fever,  acute  gastro-intestinal  disturbances,  worms  in  intestines, 
teething,  the  hydrocephaloid  disease  of  anemia  and  cerebro- 
spinal meningitis. 

Acute  meningitis  is  distinguished  by  its  sudden  invasion  with- 
out prodromatous  stage,  family  history,  previous  health,  inten- 
sity of  symptoms  and  duration,  which  is  much  shorter. 

The  early  period  of  typhoid  resembles  meningitis,  but  the 
coated  tongue,  diarrhea,  enlarged  spleen,  tympanites,  abdom- 
inal tenderness  and  gurgling,  the  eruption  and  the  characteris- 
tic temperature  curve,  will  decide  the  diagnosis. 

Intestinal  irritation  from  worms  very  closely  resembles  tuber- 
cular meningitis,  and  is  at  first  very  hard  to  differentiate,  but  a 
close  observation  of  the  case,  family  history  and  course  of  the 
attack,  high  temperature,  etc.,  after  careful  analysis  ought  not 
to  mislead  very  long  in  the  case. 

The  hydrocephaloid  condition  spoken  of  is  due  to  exhaus- 
tion and  nervousness,  caused  by  improper  nourishment,  or  im- 
paired digestion,  and  thus  readily  excluded. 

Cerebro-spinal  meningitis,  usually  epidemic,  is  distinguished 
by  sudden  and  acute  attack,  intensity  of  symptoms,  the  erup- 
tion, and  prominence  of  spinal  symptoms.  There  are  rare 
cases  of  cerebral  irritation,  which  closely  simulate  tubercular 
meningitis.  When  it  is  impossible  to  say  just  what  the  mat- 
ter is,  sometimes  called  cerebral  congestion  or  brain  fever. 
Such  a  case  runs  a  longer  course  with  varying  symptoms,  all 
pointing  unmistakably  to  brain  affection,  and  finally  gets 
well.  There  is  nothing  to  do  in  such  a  case  but  to  withhold 
a  positive  opinion,  treat  existing  conditions  as  we  find  them, 
and  wait. 

Prognosis. — After  the  case  has  passed  the  prodromal  stage 
and  progressed  to  the  second  with  deposit  of  tubercles,  the 
prognosis  is  very  grave,  and  ev  ^n  should  we  succeed  in  staying 
the  disease  of  the  brain,  it  is  only  to  see  tuberculosis  of  the 
lungs  develop,  or  a  recurrence  of  the  brain  symptoms. 

Pepper,  in  his  work  on  "  Diseases  of  Children,"  says:  "  That 


748  THE  DISEASES  OF  CHILDREN. 

in  almost  all  cases  of  reported  recovery,  the  diagnosis  was 
erroneous." 

Treatment.  —  Jahr,  in  his  "Forty  Years'  Practice,"  thus 
speaks  of  his  treatment  of  meningitis  :  "  This  disease,  which  is 
so  apt  to  run  into  acute  hydrocephalus,  is  curable  by  homeo- 
pathic means  under  almost  any  circumstances,  as  long  as  it  still 
retains  the  form  of  meningitis  and  the  physician  recognizes  its 
true  character  at  the  outset.  Under  a  proper  treatment,  all 
danger  to  life  sometimes  disappears  in  forty-eight  hours.  Only 
no  time  must  be  lost  with  aconite,  which  has  never  been  of  the 
least  service  to  me,  but  bell.  30th,  has  at  once  to  be  given,  a 
teaspoonful  of  a  solution  of  three  globules  in  water  every  three 
hours.  In  most  cases  a  decided  improvement  will  be  noticed, 
even  after  the  lapse  of  only  twenty-four  hours,  and  not  unfre- 
quently  this  remedy  alone  will  be  found  sufficient  to  completely 
restore  the  patient's  health.  If  the  physician  is  called  too  late 
and  effusion  has  already  begun  to  set  in,  bell,  will  sometimes 
fail  us  ;  in  such  a  case  I  approve,  with  the  fullest  conviction,  of 
Wahle's  recommendation  of  bryon.  30th,  one  globule  dry  on  the 
tongue,  and  still  more  of  sulph.  30th,  administered  in  the  same 
manner,  which  has  altogether  rendered  me  most  efficient  serv- 
ice in  the  meningitis  of  children.  It  should  be  remembered 
that  sulph.  does  better  after  several  other  remedies  have  been 
given  first,  than  when  the  treatment  is  begun  with  this  agents 
If  the  disease  has  entered  upon  its  third  stage,  that  of  fully-de- 
veloped effusion,  not  much  can  be  expected  either  of  bell,  or 
bryon.,  but,  unless  it  should  be  too  late  to  do  anything  for  the 
patient,  a  great  deal  may  yet  be  accomplished  by  means  of 
helleb.,  which  has  likewise  been  recommended  by  Wahle  ;  and 
still  more  certainly  by  sulph.,  and  perhaps  by  apis,  which,  in 
one  case  at  least,  where  I  had  given  up  all  hope  of  saving  the 
little  patient,  and  only  gave  this  remedy  as  a  last  resort,  had 
such  a  marked  effect  that  a  single  dose  of  sulph.  proved  after- 
wards sufficient  to  restore  this  very  sick  child  to  perfect 
health." 

Jahr  also  says  this  of  cuprum  :  "  One  of  the  most  admirable 
brain  remedies,  if  indicated  by  spasms  in  the  fingers  or  toes, 
oppression  on  the  chest,  lockjaw.  If  the  cerebral  disease  de- 
velops itself  after  suppression  of  erysipelas  or  some  other  epup- 
tion,  or  even  after  suppressed  catarrh,  or  during  the  process  of 
dentition,  I  prefer  cuprum  to  bell." 

The  consummate  faith  in  the  higher  potencies  held  by  the 
early  leaders  of  our  school,  excites  our  unbounded  admiration. 
There  is  no  question  but  their  faith  was  well  founded.  What 
is  the  trouble  now  ?  Is  it  because  the  course  of  disease 
has  changed,  or  that  infantile  constitutions  have  become  less 


TUBERCULAR  MENINGITIS.  749 

responsive  to  our  attenuated  remedies,  or  have  we  lost,  to  some 
extent,  the  art  of  accurate  prescribing?  Certain  it  is  we  do 
not,  in  these  degenerate  days,  get  the  same  results  claimed  by 
the  early  prescribers. 

However  it  be,  tubercular  meningitis  is,  at  the  present  day, 
one  of  the  most  obstinate  and  intractable  diseases  which  we 
have  to  encounter.  Cases,  however,  do  recover,  and  if  early 
enough  recognized,  there  is  ground  for  hope  that  our  efforts 
and  remedies  may  prove  effectual.  In  addition  to  the  remedies 
above  mentioned,  there  are  others  which  have  seemed  to  abate 
the  incipient  disease,  or  postpone  the  inevitable  result.  Among 
these  are  gelsemium  and  veratruni  viride,  but  their  indications 
are  too  well  known  to  require  repetition  here.  During  the 
comatose  stage,  opium  will  be  found  most  serviceable.  It  has 
no  influence  over  the  effusion  or  thickening,  but  it  relieves  the 
venous  stasis  and  arouses  the  torpid  circulation  of  the  brain. 

Zinc  is  one  of  the  great  brain  remedies,  and  is  especially  use- 
ful when  cerebral  paralysis  seems  impending.  Dr.  Hale  prefers 
the  phosphid.  My  own  experience  has  been  more  with  zincum 
met.  and  valerianate.  Camphora,  especially  the  mono-bromid 
of  camphor,  is  a  remedy  of  great  value  in  the  stage  or  irritation 
before  the  disease  has  become  fully  established. 

Dr.  J.  Compton  Burnett,  in  his  work  on  "Tuberculosis," 
reports  many  cases  of  genuine  tubercular  meningitis  cured  with 
tuber culinum,  in  the  30th  and  higher  potencies. 

Dr.  T.  F.  Allen  emphasizes  the  power  of  kali  card.  The 
kali  carb.  patient  may  be  fat,  flabby  and  exhausted,  "but  is 
always  anemic.  He  is  chilly,  never  has  fever,  and  is  worse 
from  exposure — especially  to  damp  air."  This  is  undoubtedly 
a  powerful  constitutional  remedy  in  the  early  stage  of  tubercu- 
lar meningitis,  and  should  not  be  forgotten.  ♦ 

Children  with  meningitis  must  be  kept  very  quiet  and  free 
from  all  excitement.  Plenty  of  fresh  air,  wholesome,  unstim- 
ulating  food,  regularity  of  daily  life  are  essential  hygienic 
adjuvants. 


CHAPTER  XIII. 

HYDROCEPHALUS. 

The  amount  of  fluid  in  the  brain  varies  under  different 
physiological  conditions.  This  is  especially  true  as  to  age  and 
sex.  The  proportion  of  water  is  gradually  diminished  from 
birth  to  the  age  of  twenty,  after  which  it  gradually  increases. 
It  is  greater  in  the  male  than  in  the  female.  In  adults,  the 
proportion  of  water  is  greater  in  the  gray  matter  than  in  the 
white,  while  in  infants  the  reverse  is  the  case.  Acute  disease 
very  generally  causes  an  increase  in  the  quantity  of  water  in 
the  brain  tissue  and  its  cavities.  This  increase  is  most  marked 
in  meningitis  and  hydrocephalus. 

Hydrocephalus  is  a  condition  in  which  there  is  a  gradual 
accumulation  of  serous  fluid  within  the  cranium  ;  in  most  cases 
in  the  cavities  of  the  ventricles ;  quite  rarely  in  the  arachnoidal 
space.  The  effusion  produces  pressure,  expanding  the  cranial 
contents  and  the  soft,  yielding  bones,  causing  the  head  to  en- 
large. Those  cases  developing  the  disease  after  the  bony 
structures  have  become  more  firm,  will  exhibit  less  of  this  almost 
characteristic  deformity. 

It  is  a  disease  almost  exclusively  of  infancy  and  early  child- 
hood, and  often  congenital.  Even  those  cases  in  which  the  ex- 
cess of  fluid  is  not  appreciable  at  birth,  but  makes  its  appearance 
very  sooh  after,  are  congenital,  since  the  vice  operating  to  pro- 
duce it,  probably  exists  before  birth. 

I  shall  consider  the  disease  only  in  its  chronic  form,  congen- 
ital and  acquired,  leaving  the  various  dropsies  of  the  brain  re- 
sulting from  meningitis  and  other  acute  diseases  to  be  described 
in  connection  with  those  affections. 

If  the  disease  is  plainly  present  at  the  time  of  birth,  it  may 
present  a  serious  impediment  to  delivery,  even  necessitating 
perforation  of  the  membranes.  Under  the  influence  of  violent 
uterine  contractions,  the  membranes  and  scalp  have  been  known 
to  give  way,  and  the  contents  discharged,  followed  by  speedy 
termination  of  labor. 

The  anatomical  changes  and  the  clinical  course  of  the  disease^ 

in  either  congenital  or  acquired  hydrocephalus,  are  not  suffl- 

ciently  different  to  necessitate  a  separate  description.     It  is» 

however,  a  fairly  well-established  fact  that  the  cases  of  congenital 

(750) 


HTDR  O  CEPHA  L  US.  751 

hydrocephalus  generally  present  a  more  extreme  development 
of  the  symptoms  than  when  the  disease  is  acquired. 
•  The  etiology  of  hydrocephalus  is  still  somewhat  uncertain. 
It  is  often  hereditary.  Dissipation  of  all  kinds,  lead  poisoning, 
syphilis,  tuberculosis,  and  struma  in  the  parents  are  supposed 
to  predispose  to  the  disease.  Certain  it  is  that  a  woman  who 
has  once  given  birth  to  a  hydrocephalic  child,  is  very  liable  to 
have  the  succeeding  children  hydrocephalic. 

A  large  proportiorl  of  the  cases  of  congenital  hydrocephalus 
are  no  doubt  due  to  a  low  type  of  inflammation  of  the  lining 
membranes  of  the  ventricles,  beginning  during  fetal  life,  and 
continuing  after  birth.  There  may  or  may  not  be  post-mortem 
evidences  of  such  inflammation. 

In  the  acquired  cases  a  frequent  cause  is  obstruction  to  the 
venous  circulation  in  the  brain.  This  may  be  caused  by  pres- 
sure on  the  return  vessels  or  sinuses,  either  by  tumors,  tubercu- 
lar deposits,  or  cysts,  within  or  without  the  brain,  causing  con- 
gestion of  the  ventricular  membranes.  Enlarged  glands  of  the 
neck  may  produce  the  same  result  by  causing  pressure  on  the 
veins  emerging  from  within  the  skull.  No  doubt  the  most  fre- 
quent cause  of  this  disease  is  some  constitutional  taint,  result- 
ing from  an  anemic,  scrofulous,  or  rachitic  condition,  or  by 
acute  disease  in  which  the  blood  has  become  impoverished. 

Morbid  Anatomy. — The  alterations  in  the  bony  parts  of  the 
head  are  marked.  Those  bones  which  enter  into  the  formation 
of  the  dome  or  arch  are  most  markedly  affected.  The  vertical 
portion  of  the  frontal,  the  parietal,  the  squamous  portions  of 
the  temporal,  and  the  upper  part  of  the  occipital  bone  are  all 
thinned  and  often  elastic  and  enlarged  much  beyond  their  nat- 
ural area.  The  size  of  the  sutures  and  the  fontanel  are  in- 
creased and  fluctuation  can  readily  be  detected  in  them.  If  the 
amount  of  fluid  is  large,  the  frontal  bone  is  tipped  forward  and 
the  direction  of  the  orbits  are  changed,  and  the  eyes  present  a 
peculiar  appearance,  having  the  lower  portion  of  the  cornea 
hidden  under  the  lower  lid,  while  a  distinct  line  of  the  white 
sclerotic  is  visible  between  the  upper  margin  and  the  upper  lid. 

The  contour  of  the  head  is  rarely  regular,  the  sides  usually 
bulging,  causing  the  top  to  appear  rather  flat.  This  gives  the 
face  a  peculiar  triangular  appearance,  the  triangle  being  in- 
verted, the  top  of  the  head  forming  the  base  and  the  chin  the 
apex.  The  bones  at  the  base  of  the  skull  are  little  affected, 
though  cases  have  been  reported  where  even  here  there  had 
been  decided  displacement.  In  rare  cases,  where  the  amount 
of  the  effusion  is  not  so  great,  the  size  of  the  head  is  not  so  ap- 
parent, and  the  displacements  not  so  marked ;  but  usually  a 
well-marked  case  will  present  the  appearance  described. 


752  THE  DISEASES  OF  CHILDREN. 

In  acquired  hydrocephalus,  making  its  appearance  after  the 
bones  of  the  skull  are  more  or  less  firmly  united,  the  bony  de- 
formity of  the  head  may  be  scarcely  perceptible. 

The  quantity  of  the  effusion  may  be  anything  from  normal 
to  eight,  ten,  and  even  twenty  pints.  The  usual  amount,  how- 
ever, is  not  so  great,  and  generally  there  is  present  not  more 
than  a  pint  or  two.  In  the  acquired  cases  there  may  be  only  a 
few  ounces.  The  fluid  is  clear,  or  slightly  turbid,  and  of  higher 
specific  gravity  than  normal  cerebro-spinal  fluid.  It  is  alkaline 
in  reaction  and  contains  more  or  less  albumin,  the  percentage 
of  albumin,  according  to  Huguenin,  being  in  direct  ratio  to  the 
activity  of  the  inflammation. 

The  effect  of  this  effusion  in  the  cavities  of  the  brain  is  to 
expand  them  in  all  directions.  The  cerebral  substance,  by  be- 
ing compressed  between  the  fluid  and  the  skull,  is  greatly 
thinned  and  distended,  at  times  constituting  a  mere  shell.  The 
ventricles  are  in  free  communication,  and  the  septum  lucidum  is 
torn  or  entirely  obliterated.  The  foramen  of  Monro,  and  the 
aqueduct  between  the  third  and  fourth  ventricles  are  distended. 
The  structures  on  the  floor  suffer  equal  distortion.  The  cor- 
pora striata  are  separated  and  very  much  flattened.  The  crura, 
the  corpora  quadrigemina,  the  optic  thalami,  the  optic  tracts,  the 
cerebellum  and  the  pons  are  all  flattened.  The  convolutions  on 
the  surface  of  the  brain  are  completely  obliterated. 

The  membranes  lining  the  ventricles  often  present  thickened 
surfaces,  and  opaque  patches,  but  these  evidences  of  inflamma- 
tion are  not  always  present,  even  in  cases  supposed  to  be  of 
inflammatory  origin.  In  the  acquired  form,  where  the  struct- 
ures are  more  firm  and  the  fluid  less,  the  linings  of  the  ventri- 
cles show  more  marked  inflammatory  changes,  the  structures 
on  the  floor  being  dotted  over  with  small  nodules. 

If  the  fluid  is  in  the  arachnoidal  space,  "  external  hydroceph- 
alus," it  is  spread  more  or  less  evenly  over  the  surface  of  the 
brain.  The  brain  substance  is  likely  to  be  softened,  or  even 
reduced  to  a  pulpy  consistence  on  the  surface.  The  fluid  in 
such  cases  will  be  more  dense,  and  the  evidence  of  inflamma- 
tory action  more  apparent.  Such  cases  should  be  properly 
considered  as  meningitis  with  effusion,  and  not  as  hydro- 
cephalus. 

Symptoms. — The  prominent  symptom  is  the  large  head. 
This  is  especially  true  in  congenital,  or  early-acquired  cases. 
The  head  grows  steadily,  but  there  is  a  marked  lack  of  corre- 
sponding bodily  growth.  The  head  and  abdomen  are  large,  but 
the  arms,  legs,  and  chest  are  thin  and  small.  As  the  head  in- 
creases in  size  the  child  is  unable  to  hold  it  up,  and  may  sup- 
port it  with  the  hands,  and  later  can  only  rest  it  on  a  pillow. 


HTDROCEPHALUS.  758 

If  the  progress  of  the  disease  is  slower,  and  the  child  reaches 
the  age  when  other  children  learn  to  walk,  it  will  not  make  an 
effort,  and  if  placed  on  its  feet  will  not  "  brace  "  itself,  but  will 
sink  helplessly  down.  If  it  learns  to  walk,  it  will  be  a  slow 
process,  and  the  gait  will  be  unsteady  and  uncertain. 

The  mental  development  depends  upon  the  effusion.  The 
greater  the  quantity,  the  less  the  development.  Early  in  the 
case,  the  child  may  seem  simply  a  little  backward.  There  may 
be  no  development,  or  very  little,  or  there  may  be  actual  loss 
of  mentality ;  in  fact,  there  may  be  any  condition,  from  simple 
feeble-mindedness  to  actual  idiocy.  In  other  cases,  the  mental 
faculties  are  not  much  disturbed  early,  and  for  a  time  seem  to 
develop  normally.  It  is  even  possible  for  marked  enlargement 
of  the  head  to  take  place,  without  any  indication  of  pressure 
on  the  brain  centers.  Dr.  Bastian  reported  a  case  in  which  the 
head  measured  twenty-four  inches  in  circumference  at  the  age 
of  two  and  a  half  years,  with  no  brain  symptoms  or  other  dis- 
turbances. This  child's  head  had  been  steadily  enlarging  for 
eighteen  months.  Such  cases  are  extremely  rare,  for  nervous 
symptoms  are  seldom  absent,  even  early  in  the  case,  and  in 
many  instances  they  are  the  first  evidences  of  trouble,  often 
presenting  themselves  long  before  the  enlargement  of  the  head 
is  noticed. 

In  these  cases,  the  first  symptom  of  central  irritation  is 
likely  to  be  a  convulsion.  These  attacks  may,  at  first,  be  infre- 
quent, becoming  more  and  more  frequent  as  the  case  progresses. 
There  may  be  slight  twitchings  of  the  face,  rolling  of  the  eyes, 
or  pronounced  general  convulsions.  The  enlargement  of  the 
head  is,  in  rare  cases,  preceded  by  symptoms  of  trouble  at  the 
base  of  the  brain.  Dr.  Bastian  reports  the  case  of  a  child  four 
years  old,  who  fell,  striking  the  back  of  the  head  with  great 
force.  Soon  after  it  presented  symptoms  of  cerebellar  irrita- 
tion. In  a  year  or  more  the  head  began  to  enlarge,  and  hydro- 
cephalus constituted  the  prominent  condition. 

Pain  in  the  head  is  always  a  prominent  symptom,  even  young 
infants  showing  that  they  suffer,  by  frequently  crying  and 
moaning,  and  placing  the  hands  on  various  parts  of  the  head. 
The  constant  rolling  of  the  head  on  the  pillow,  often  so  mark- 
edly present,  is  no  doubt  due  to  this  cause. 

The  symptoms  in  acquired  hydrocephalus  and  those  in  con- 
genital cases  are  much  the  same,  except  in  cases  that  begin 
after  the  bones  of  the  skull  have  become  more  or  less  firmly 
united.  The  symptoms  then  are  obscure,  for  the  signs  of 
distention  are  not  visible.  The  child  becomes  dull  and  languid  ; 
there  is  headache,  dizziness,  disinclination  to  play,  and  it  is 
easily  fatigued.  It  sits  about  and  rests  its  head  upon  the  hands, 
D.  C— 48 


754  THE  DISEASES  OF  CHILDREN. 

or  in  other  ways  supports  it.  The  gait  becomes  unsteady  and 
irregular,  and  twitchings  and  a  tendency  to  convulsions  are 
frequent.  The  pupils  react  slowly,  and  finally  become  dilated, 
and  epileptiform  seizures,  followed  by  vomiting  and  severe 
headache,  are  more  or  less  frequent.  There  may  be  numbness 
of  the  hands  and  feet,  paralysis  of  certain  extremities,  hemi- 
plegia or  complete  inability  to  walk  or  even  stand.  Nystagmus 
and  strabismus  are  often  present,  and  not  infrequently  loss  of 
vision.  The  senses  of  hearing  and  smell  may  also  be  impaired, 
but  not  so  frequently  or  markedly  as  that  of  vision. 

The  appetite  in  most  cases  is  good  or  even  voracious.  Di- 
gestion may  be  unimpaired,  even  in  gluttony,  and  yet,  while  in 
some  instances  the  child  may  be  fairly  well  nourished,  the  great 
majority  early  show  signs  of  failing  nutrition.  This  becomes 
more  marked  as  the  disease  progresses.  The  body  grows  thin, 
the  muscles  atrophy,  the  skin  becomes  dry,  the  abdomen  grows 
tympanitic,  and  little  resistance  can  be  offered  to  other  diseases 
that  may  supervene. 

Prognosis. — Most  strictly  congenital  cases  of  hydrocephalus 
die  in  a  comparatively  short  time  after  birth,  and  many  during 
the  parturition  or  very  soon  after.  The  great  majority  do  not 
live  longer  than  from  six  months  to  two  years.  Very  rarely  a 
case  may  survive  as  long  as  three  years. 

The  duration  of  the  disease  is,  however,  extremely  variable. 
While  the  course  in  congenital  cases  is  usually  very  rapid  and 
death  may  result  in  a  few  months,  some  of  the  children  in 
which  the  disease  is  acquired  later  in  infancy  or  in  early  child- 
hood, may  live  to  reach  the  age  of  five,  six,  or  eight  years. 
The  duration  of  those  cases  in  which  the  disease  begins  after 
the  bones  of  the  skull  have  become  united  quite  firmly,  and 
which  present  the  nervous  phenomena  described  above  early  in 
the  case,  will  depend  upon  the  activity  of  the  disease  and  the 
rapidity  with  which  the  serum  is  effused. 

Most  cases  that  run  a  long  course  are  marked  by  more  or 
less  distinct  periods  of  remission,  when  the  head  ceases  to  en- 
large and  general  nutrition  improves.  These  periods  vary  in 
duration,  sometimes  continuing  long  enough  to  encourage  the 
the  belief  that  the  disease  has  been  arrested.  Disappointment, 
however,  is  almost  sure  to  follow.  Even  if  the  disease  is  ar- 
rested and  the  sutures  ossify  and  the  fontanels  are  filled  in, 
there  remains  the  abnormally  large  head  and  a  more  or  less 
impaired  intelligence. 

Dr.  L.  W.  Sedgwick  reported  a  most  interesting  case  in  which 
the  termination  of  a  decidedly  hydrocephalic  condition  occurred 
by  spontaneous  evacuation  through  the  nose.  The  little  pa- 
tient was  two  years  old.     Two  of  his  brothers  had  died  of  hy- 


HTDROCEPHALUS.  755 

drocephalus.  He  had  had  a  large  head  since  birth.  He  com- 
plained frequently  of  headache,  became  listless,  and  often 
wanted  to  lie  down.  His  sleep  was  restless,  and  he  often 
awoke  with  a  scream.  The  head  began  to  enlarge,  and  soon 
the  fontanels  as  well.  The  symptoms  of  brain  pressure,  such 
as  dilated  pupils,  disturbed  respiration,  insensibility  to  sur. 
roundings,  etc.,  made  their  appearance  and  progressed  to  such 
a  degree  as  to  make  the  case  appear  every  day  more  hopeless. 
At  this  stage  a  copious  watery  discharge  from  the  nose  made 
its  appearance,  and  gradually  all  the  threatening  symptoms  dis- 
appeared. After  the  lapse  of  a  year,  they  again  made  their 
appearance,  and  were  again,  and  this  time  permanently,  relieved 
in  the  same  manner. 

Another  similar  case  of  spontaneous  evacuation  was  reported 
by  Barron.  This  child  died,  and  the  autopsy  disclosed  a  small 
opening  through  the  ethmoid  bone  from  the  cranium  to  the 
nose. 

When  death  results  directly  from  hydrocephalus,  it  is  caused 
by  the  gradually  increasing  pressure  of  the  accumulating  fluid. 
The  child  becomes  comatose,  and  remains  in  this  condition  to 
the  end.     Death  is  due  to  complete  arrest  of  brain  function. 

Hydrocephalic  children  are  extremely  liable  to  acute  diseases. 
Bronchitis,  pneumonia,  intestinal  disorders,  or  some  of  the 
eruptive  diseases  frequently  terminate  the  lives  of  these  little 
sufferers. 

It  is  not  uncommon  to  find,,  associated  with  congenital  hy- 
drocephalus, other  malformations,  such  as  spina  bifida,  cleft 
palate,  and  hare  lip.  Spina  bifida  is  probably  the  most  fre- 
quent, due,  no  doubt,  to  the  increased  pressure  of  the  exces- 
sive fluid,  preventing  normal  closure  of  the  canal.  Webbed 
fingers  and  toes,  and  impervious  nostrils  have  also  been  noted. 

Treatment. — In  a  disease  which  results  so  generally  unfavor- 
ably, very  little  satisfaction  is  derived  from  the  use  of  drugs. 
Of  all  the  medicines,  which  the  old  school  has  used  to  check 
or  reduce  the  amount  of  the  fluid,  the  iodid  of  potash  alone 
has  kept  a  place  with  them.  This  is  still  given  in  moderately 
large  doses,  and  in  some  cases  has  appeared  to  be  beneficial. 

Eustace  Smith  still  holds  that  the  chlorid  of  mercury,  per- 
sistently given,  will,  and  often  has,  succeeded  in  arresting  the 
disease.  This  opinion  is  not  shared  by  other  equally  close  ob- 
servers. Homeopathically  such  remedies  as  apis  mel.,  arsenic 
alb,,  calc.  carb.,  calc.  phos.,  cina,  ferrum  phos.,  helleb.,  sulphur 
and  zinc  might  be  expected  to  be  of  benefit  in  this  condition  ; 
but  experience  has  done  little  to  confirm  this  expectation  so 
far  as  the  ultimate  termination  of  the  disease  is  concerned. 

Compression  by  elastic  bandages  or  adhesive  straps  has  been 


T56  THE  DISEASES  OF  CHILDREN. 

quite  generally  employed  with  doubtful  benefit.  If  the  elastic 
is  employed,  it  should  be  applied  "just  tight  enough  not  to  have 
the  material  impress  its  pattern  on  the  skin."  In  using  the  adhesive 
strips  great  care  is  necessary  not  to  apply  them  too  tight,  and 
they  must  be  removed  and  reapplied  at  intervals.  Should  symp- 
toms of  pressure  make  their  appearance,  the  bandages  or  strips 
must  be  removed  at  once,  and  may  be  reapplied.  Dr.  Dickin- 
son and  Dr.  J.  Lewis  Smith  have  each  expressed  the  belief  that 
the  rapidity  of  the  effusion  may  in  this  way  be  modified.  Punc- 
ture and  partial  evacuation  of  the  fluid  has  been  frequently 
performed,  but  the  effect  has  been  merely  to  give  temporary 
relief,  since  the  reaccumulation  of  fluid  is  sure  to  follow,  and 
usually  more  rapidly  after  each  puncture.  There  is,  besides, 
some  danger  of  setting  up  active  traumatic  meningitis,  though  J. 
Lewis  Smith  characterizes  the  operation  as  "  simple,  devoid  of 
danger,  and  easily  performed."  He  makes  the  puncture  at  the 
outer  angle  of  the  anterior  fontanel,  and  removes  only  a  small 
quantity  each  time,  and  keeps  constant  pressure  applied  by 
means  of  adhesive  straps. 

The  careful  attention  to  the  general  health  of  the  child  is  of 
the  highest  importance  in  this  disease.  It  should  be  very  care- 
fully fed.  The  general  nutrition  must  be  kept  as  good  as  pos- 
sible. Since  the  disease  is  so  frequently  associated  with  a  ra- 
chitic condition,  the  remedies  suggested  by  this  diathesis  will 
often  be  indicated.  Any  disturbance  of  the  digestive  organs 
must  be  promptly  corrected  and  the  general  hygiene  carefully 
regulated. 


PART    XII. 

DISEASES  OF  THE  SKIN. 


CHAPTER   I. 
ECZEMA     (CRUSTA     LACTEA — MOIST     TETTER — SALT-RHEUM). 

Definition. — Eczema  is  an  acute  or  chronic  non-contagious 
inflammation  of  the  skin,  characterized  by  an  eruption  which 
may  be  erythematous,  papular,  vesicular  or  pustular,  or  else 
a  combination  of  these  forms,  attended  by  more  or  less  infiltra- 
tion and  itching,  terminating  either  in  discharge  with  the  forma- 
tion of  crusts,  or  in  desquamation. 

It  is  most  protean  in  its  manifestations,  may  involve  a  cir- 
cumscribed area,  or  more  rarely  cover  extensive  surfaces,  and 
is  often  extremely  persistent. 

It  may  begin  with  a  slight  erythema  of  the  skin,  accompa- 
nied by  a  sensation  of  itching  and  burning,  which,  as  the  dis- 
ease advances,  becomes  almost  intolerable ;  soon  an  exudation 
is  noticed,  that  rapidly  dries  into  fine  scales ;  and,  after  these 
scales  desquamate,  the  skin  is  left  in  a  thickened  and  dry  con- 
dition. 

Or  it  may  present  vesiculation  or  pustulation  as  the  first 
noticeable  symptom,  followed  by  a  sense  of  heat  and  swelling. 
The  vesicles  or  pustules,  as  the  case  may  be,  according  to  the 
number  of  leucocytes  which  the  contained  fluid  holds,  soon 
rupture,  and  thick  yellowish  or  greenish  crusts  are  formed,  sit- 
uated on  an  inflamed  and  exuding  surface.  These  crusts  con- 
tinue to  form  for  some  time,  when  suddenly  the  character  of  the 
eruption  may  change,  the  exudation  ceases,  and  no  more  crusts 
form,  and  instead  of  the  inflamed  and  exuding  surface,  the  skin 
will  become  dry  and  desquamate  in  fine  dry  scales,  leaving  the 
integument  in  a  fissured  and  infiltrated  condition. 

Or  it  may  make  its  appearance  in  the  form  of  papules,  which 
may  either  preserve  their  special  characteristics  throughout 
their  course,  or  pa*;s  into  other  lesions. 

Eczema  is  no  respecter  of  age,  sex,  race  or  conditions  of  life. 
Infants  of  a  tender  age  are  subject  to  it,  and  it  is  often  one  of 
the  first  diseases  to  attack  the  new-born.     It  has  no  particular 

(757) 


758  THE  DISEASES  OF  CHILDREN. 

section  of  the  country  to  which  it  confines  its  ravages,  and  is 
met  with  in  country  as  well  as  in  city  practice. 

It  does  not  confine  its  invasions  to  the  poor,  who  are  quar- 
tered in  hovels  and  surrounded  by  filth  and  squalor,  but  often 
finds  its  way  into  the  palaces  of  the  rich,  and  many  are  the  pa- 
tients, reared  in  the  lap  of  luxury,  that  come  under  the  physi- 
cian's care  for  relief  from  its  terrible  irritation. 

No  particular  portion  of  the  body  can  be  called  its  favorite 
seat,  for  it  is  met  with  on  the  scalp,  face,  neck,  body,  extremi- 
ties, folds  of  the  skin,  the  hands  and  the  feet. 

Eczema,  while  met  with  at  all  ages,  is  preeminently  a  disease 
of  childhood. 

In  a  practice  covering  a  period  of  nearly  thirty  years  in  this 
city,  it  has  been  our  experience  that  about  forty  per  cent,  of 
all  skin  diseases  are  eczematous ;  and  further,  that  about  forty 
per  cent,  of  all  cases  of  eczema  occur  in  children  under  ten 
years  of  age. 

A  careful  study  of  cases  occurring  in  individuals  of  varying  age 
will  reveal  the  fact  that  the  disease  tends  to  descend  from  the 
upper  portion  of  the  body  to  the  lower,  as  the  person  grows 
older  ;  for  the  head,  and  most  particularly  the  scalp,  is  affected 
in  infancy  and  youth  ;  in  adult  life,  the  genitals,  from  their 
functional  activity,  and  the  trunk  are  mainly  involved  ;  and  as 
old  age  gradually  and  silently  overtakes  the  patient,  the  disease 
creeps  down  to  the  lower  extremities  and  to  the  feet. 

Etiology. — The  causes  of  eczema  are  external  and  internal. 
The  common  external  causes  are  irritations  of  a  mechanical, 
chemical  or  thermic  nature.  The  principal  internal  causes  are 
irritation  of  the  alimentary  canal,  deficient  functional  activity 
of  the  kidneys,  hepatic  derangement,  and  vital  depression.  In 
most  cases  it  is  probable  that  the  chief  factor  is  reflex  irritation 
of  the  nervous  centers,  producing  a  dilatation  of  the  capillaries 
in  the  different  regions  of  the  skin  affected.  Transmitted  ten- 
dencies are  believed  by  some  to  play  a  not  unimportant  part  in 
its  causation.  Dentition,  also,  is  a  prominent  cause,  and  while 
the  process  is  a  physiological  one,  and  in  its  normal  procedure 
should  cause  no  systemic  disturbances  yet  when  the  teeth  are 
delayed,  or  when  from  a  tough  gum  they  cause  pressure  on  the 
dental  nerve  terminals,  then  by  reflex  irritation  they  have  the 
power  of  setting  up  an  inflammation  of  the  skin  which,  in  those 
having  a  weak  and  delicate  integument,  will  frequently  become 
eczematous ;  and  anything  which  tends  to  lower  the  vitality  of 
the  system,  combined  with  impaired  nutrition  and  disturbed 
circulation,  may  give  rise  to  an  attack  of  this  disease.  It  is  not 
uncommon  to  find  a  reflex  neurotic  eczema  associated  with  an 
adherent  prepuce. 


ECZEMA— ETIOLOGT.  759 

The  idea  that  vaccination  causes  eczema  was  widely  accepted 
by  both  physicians  and  laity  at  the  beginning  of  this  century, 
and  doubtless,  had  some  apparent  facts  to  support  it.  This 
idea  is  easily  explained  by  the  theory  of  latent  disease,  and  it 
is  possible  that  when  the  disease  follows  upon  vaccination  a  close 
examination  of  the  child  would  probably  reveal  plenty  of  evi- 
dence pointing  to  an  eczematous  tendency,  either  from  the 
child's  history,  or  symptoms  prior  to  the  operation,  or  from 
the  history  of  the  parents,  and  the  vaccination  had  simply 
aroused  this  latent  disease  into  activity,  but  had  not  caused  it. 
However,  the  best  plan  to  pursue,  when  about  to  vaccinate,  is 
conservatism  ;  and  unless  the  vaccination  is  imperative,  to 
wait  until  the  eczema  is  cured,  or  its  presence  disproved. 

A  common  external  cause  of  eczema  in  the  new-born  is  the 
injudicious  treatment  it  receives  during  the  twenty-four  hours 
following  its  birth.  The  sudden  exposure  of  the  skin  to  a 
change  of  nearly  thirty  degrees  of  temperature  ;  the  anointing 
of  the  surface  with  inferior,  and  often  rancid  oil ;  the  carelessly 
administered  initial  bath  with  its  chilling  water,  coarse  cloth  or 
rough  sponge,  irritating  alkali  soap,  and  rough  towel ;  the 
coarse,  cumbersome  and  illy-adjusted  napkin  and  pinning 
blanket ;  the  large  and  often  misapplied  binder,  all  tend  to  fret 
the  baby,  and  not  infrequently  so  irritate  the  integument  as  to 
induce  a  congestion  or  a  follicular  inflammation  which  may  be 
a  starting  point  for  a  widespread  eczema. 

Often  the  vernix  caseosa  at  the  first  washing  is  imperfectly 
removed  from  the  scalp,  and  this  being  allowed  to  dry  and  de- 
compose, induces  an  inflammation  which  becomes  an  eczema 
unless  checked.  Besides  this,  other  causes  are  at  work.  Not 
infrequently,  through  the  carelessness  of  the  mother  or  nurse, 
the  napkins  are  not  changed  as  often  as  necessary,  and  the  feces 
are  thereby  left  to  ooze  into  the  folds  of  the  skin  around  the 
thighs  and  anal  region,  where  they  dry,  and  their  sharp  edges 
cut  and  irritate  the  tender  skin  ;  or  the  urine  flows  over  the 
genitals,  scalding  and  burning  them  ;  and  the  milk  is  vomited, 
saturates  the  clothing  around  the  neck,  and  unchanged,  is  left 
for  hours.  All  these  causes  cannot  fail  to  produce  that  con- 
dition of  skin  known  as  intertrigo,  which  is  but  a  step  removed 
from  eczema. 

Then  again,  it  is  not  improbable  that  certain  micro-organisms 
which  float  in  the  air,  or  are  contained  in  the  water  used  in  the 
bath,  play  a  very  important  part  in  the  development  and  con- 
tinuance of  eczema  in  individuals  having  a  tendency  to  it. 

Another  etiological  factor  that  demands  attention  is  the 
abuse  of  the  nursery  materia  vicdica,  which  is  responsible  for 
a  large  number  of  cases.     Such  common  and  well-known  reme- 


760  THE  DISEASES  OF  CHILDREN. 

dies  as  castor-oil,  goose-oil,  sage-tea,  catnip-tea,  whisky,  pare- 
goric, soothing  syrups,  etc.,  are  all  given  indiscriminately,  and 
produce  this  disease  by  interfering  with  digestion  and  assimila- 
tion, or  by  irritation  of  the  nervous  system  and  lessening  of  the 
general  tone. 

Varieties. — The  varieties  of  eczema  dependent  on  the  primary 
or  characteristic   lesion  are  —  erythematous,  vesicular,  pustu- 
lar, papular,  exfoliative  and  fissured.    These  forms  may,  in  their, 
progress,  become  complicated  with  or  be  followed  by  certain 
secondary  lesions. 

The  varieties  of  eczema  dependent  on  the  activity  or  on 
the  duration  of  the  process,  are  the  acute,  and  sub-acute,  and 
the  chronic. 

The  clinical  features  of  eczematous  lesions  are  often  modified 
by  locality  ;  especially  is  this  noticeable  on  the  scalp,  face,  hands, 
feet  and  genitals. 

The  erythematous  variety  is  characterized  by  small  or  large, 
bright  or  dark-red,  slightly  desquamative  patches,  accompanied 
by  itching  or  burning.  It  is  most  commonly  located  on  the 
face  and  genitals. 

The  vesicular  variety  is  characterized  by  the  appearance  of  a 
diffuse  or  punctate  erythema,  on  which  minute,  closely-aggre- 
gated vesicles  appear,  accompanied  by  burning  and  itching. 
The  vesicles  soon  rupture,  either  spontaneously  or  from  scratch- 
ing, and  leave  a  raw,  reddened  surface,  which  becomes  covered 
with  a  yellowish,  gummy  crust.  It  is  attended  with  more  or 
less  infiltration  and  swelling,  and  the  exudation  stains  and  stiff- 
ens linen.  Its  most  common  seat  in  children  is  on  the  face 
and  scalp. 

The  pustular  variety  may  originate  from  the  vesicular  form, 
or  arise  directly,  and  consists  in  an  aggregation  of  small  pus- 
tules— larger  than  the  vesicles — which  rupture  and  form  dark, 
greenish  crusts.  It  is  most  common  in  strumous  children,  and 
its  favorite  seats  are  the  scalp  and  face. 

The  papular  variety  consists  of  small,  red,  aggregated  pap- 
ules, accompanied  by  severe  itching.  It  is  frequently  associ- 
ated with  the  vesicular  form.  It  is  apt  to  occur  on  the  arms, 
forearms,  thighs  and  legs,  especially  the  flexor  surfaces. 

The  exfoliative  variety  is  a  variety  only  from  a  clinical  stand- 
point, and  is  characterized  by  a  continuous  exfoliation  of  the 
epidermis,  generally  from  a  reddened  surface,  accompanied  by 
considerable  itching.  It  is  most  commonly  observed  on  the 
neck  and  extremities. 

The  fissured  variety  also  is  a  clinical  variety,  and  presents 
cracks  or  fissures  of  varying  size  and  depth,  which  are  often 
very  painful.     The  palms  and  soles  are  its  favorite  seats. 


ECZEMAS  TMP  TOM  A  TOL  OGT.  761 

Unna  describes  three  forms  of  infantile  eczema,  attacking 
especially  the  head  and  face — the  tubercular,  the  nervous,  and 
the  seborrheic.  The  tubercular  form  is  observed  mostly  on 
the  face,  or  in  strumous  children,  in  association  with  conjunc- 
tivitis, rhinitis  and  otorrhea.  The  nervous  form  is  due  to 
reflex  irritation  from  derangements  of  the  alimentary  canal  or 
from  teething,  and  appears  chiefly  on  the  cheeks,  forehead, 
lower  part  of  the  arm,  posterior  surface  of  the  forearm,  and 
radial  surface  of  the  back  of  the  hands  and  wrists.  The  sebor- 
rheic form  is  apt  to  be  preceded  by  a  seborrhea  of  the  scalp, 
that  makes  its  appearance  shortly  after  birth.  The  lesion  be- 
comes moist,  but  still  retains  its  fatty  character,  and  invades 
the  ears,  forehead,  eyebrows  and  cheeks.  It  is  less  irritable 
than  the  nervous  form,  and  displays  a  disposition  to  generalize 
on  the  genitals,  back  and  lower  extremities. 

The  majority  of  these  several  varieties  of  eczema  pass  through 
different  stages,  which,  for  practical  convenience,  may  be  called 
the  first,  second  and  third  stages. 

Symptomatology . — In  acute  cases,  the  first  stage  is  the  period 
characterized  mainly  by  hyperemia,  with  redness  and  vesicula- 
tion.  This  period  is  often,  but  not  always,  ushered  in  with  a 
general  malaise,  loss  of  appetite  and  more  or  less  disturbance 
of  the  circulation  ;  and  these  symptoms  are  followed  soon  by 
an  eruption  covering  a  variable  area  and  accompanied  by  heat 
and  burning.  In  a  few  hours,  or,  at  the  most,  a  day  or  two, 
after  the  appearance  of  the  eruption,  fine,  pearly  points  are  seen 
on  the  inflamed  surface,  and  with  more  or  less  itching  the  vesi- 
cles erupt.  The  vesicles  are  closely  grouped  and  are  very  small. 
They  seldom  last  more  than  twenty-four  hours,  rarely  over 
forty-eight  ;  are  made  up  mostly  of  serum  which  contains  some 
fibrin  and  a  few  leucocytes.  The  most  prominent  subjective 
symptom  now,  is  the  itching,  and  the  disease  is  entering  the 
second  stage. 

The  characteristics  of  the  second  stage  are  exudation  and 
crusting  ;  and  this  stage  may  last  an  indefinite  period.  As  the 
disease  spreads,  the  advancing  border  may  be  marked  by  new 
papules  and  vesicles  forming  ;  or  by  the  stratum  corneum  be- 
coming exfoliated.  This  pathological  phenomenon  is  one  of 
the  natural  consequences  of  the  exudation  following  the  pri- 
mary congestion,  which  instead  of  raising  the  layers  and  forming 
vesicles,  may  ooze  through  and  float  the  corneal  layer  ofT  of  the 
cells.  As  the  disease  advances  and  the  vesicles  mature,  the 
character  of  the  contained  serum  changes  ;  from  being  clear  it 
clouds,  and  finally  pus  forms,  and  the  vesicles  become  pustules, 
which  are  ruptured  either  by  friction  or  spontaneously.  Char- 
acteristic yellowish-green  scabs  are  formed  upon  the  surface 


762  THE  DISEASES  OF  CHILDREN. 

from  the  contents  of  the  pustules,  which  dry  into  these  scabs, 
soon  after  they  are  ruptured.  These  scabs  can  be  removed  by 
brisk  rubbings  with  soap  and  water,  leaving  the  skin  in  a  red- 
dened and  inflamed  condition  ;  and  on  this  reddened  and  in- 
flamed surface  numerous  fine  beads  of  exudation  soon  make 
their  appearance. 

The  third  stage  is  the  stage  of  decline  ;  and  is  characterized 
by  a  gradual  lessening  and  cessation  of  all  the  symptoms  ;  the 
exudation  decreases,  the  effusion  becomes  less,  the  crusts  grow 
thinner,  the  surface  dries,  and  instead  of  the  unsightly  scabs 
which  have  hitherto  formed,  thin,  white  scales  are  seen,  which, 
if  the  patch  tends  to  recover,  become  finer  and  adhere  more 
firmly,  and  the  skin  gradually  returns  to  its  normal  condition 
without  a  scar. 

This  is  the  typical  course  of  the  disease,  but  it  is  not  an  in- 
frequent occurrence  for  the  attack  to  stop  short  at  any  of  the 
stages  of  development,  or  advance  from  the  first  to  the  third 
stage,  skipping  the  second.  Often  the  eruption  may,  from  first 
to  last,  be  simply  erythematous  {e.  erythematosuni).  Again, 
from  a  condition  of  hyperemia,  the  disease  may  suddenly  de- 
velop small,  red  papules  and  then  linger  {e.  papulosum),  or  ves- 
icles may  be  quickly  formed  from  these  papules  {e.  vesiculosum)  ; 
while  in  another  case  the  inflammation  passes  directly  to  the 
pustular  form  {e.  pustulostini).  Lastly,  the  disease  may  run  its 
typical  course,  or  pass  over  any  of  the  first  two  stages,  and  re- 
main stationary  for  an  indefinite  length  of  time  in  the  third  stage 
{e.  sqiiamosuin). 

The  course  of  the  chronic  case  is  somewhat  varied,  for  it  may 
start  as  a  primary  affection,  or  with  acute  or  sub-acute  symp- 
toms, and  halt  in  the  second  or  third  stage,  particularly  the 
third  stage.  In  these  cases  the  invaded  surfaces  are  generally 
limited,  but  in  unusually  severe  attacks  the  eruption  may  in- 
volve the  entire  skin.  These  are  exceptions  and  are  very 
rare.  The  chronic  variety  is  more  common  than  the  acute ; 
and  when  an  eczema  takes  on  a  tendency  to  repetition,  or 
shows  definite  lines  in  its  action,  and  secondary  changes  ac- 
company these,  it  may  be  called  chronic.  These  cases  gener- 
ally have  considerable  pruritus,  and  occasionally  suffer  an  out- 
break, acute  in  character. 

When  this  disease  occurs  on  the  scalp — the  most  common 
locality  in  infants — it  passes  from  the  erythematous  and  vesic- 
ular stages  very  rapidly  to  the  pustular ;  and  the  exudation 
forms  thick,  hard,  greenish  crusts  that  are  situated  on  an  in- 
flamed and  fissured  surface.  In  the  crusts  that  are  formed  the 
hair  is  thickly  matted,  being  glued  together  by  the  thick,  puru- 
lent discharge;  and  in  appearance  is  much  like  what  honey  or 


E  CZEMA—S  2' MP  TOM  A  TOL  OGT.  763 

gum-arabic,  when  poured  on  the  scalp,  would  be.  If  this  is 
neglected  it  will  run  on  for  years,  and  very  often  abscesses 
form  from  the  retained  purulent  exudation,  and  glandular  en- 
largements are  not  rare. 

When  occurring  on  the  face  it  is  known  as  crusta  lactea. 
Here  it  is  met  with  in  various  stages,  but  it  is  mostly  symmet- 
rical, and  runs  a  straight  course. 

The  eyelids  are  prone  to  be  invaded,  and  when  so  situated  it 
is  exceedingly  troublesome.  The  margins  of  the  lids  thicken, 
inflame  and  infiltrate  ;  and  when  it  is  in  this  condition,  its  re- 
semblance to  inflammation  of  the  Meibomian  glands  is  very 
strong,  and  is  often  mistaken  for  the  latter  trouble.  The  hair 
follicles  may  become  involved,  and  partial  or  complete  loss  of 
the  eyelashes  will  result.  The  most  common  termination, 
when  occurring  about  the  nose,  is  the  formation  of  scabs. 

The  lips  and  mouth  are  often  affected  ;  and  when  the  mucous 
openings  are  invaded,  the  disease  generally  runs  a  chronic 
course  and  is  very  exasperating.  The  lips  become  edematous 
and  fissured,  besides  being  slightly  inflamed,  moist  and  scaly. 
When  occurring  here,  it  is  mostly  of  the  erythematous  form. 

A  common  and  exceedingly  troublesome  location  is  on  and 
about  the  ears.  They  are  usually  considerably  enlarged,  swol- 
len and  inflamed ;  and  these  symptoms  are  accompanied  by  a 
constant  exudation,  which  drips  down  and  hardens  into  firm 
crusts.  The  vesicles  are  generally  developed  early,  and  very 
rapidly  run  into  the  pustular  stage. 

On  the  genitals  it  often  proves  intractable,  from  the  constant 
moisture  of  the  parts.  There  is  heat  and  redness,  and  quite 
frequently  swelling  and  severe  pruritus.  Fissures,  which  are  ex- 
ceedingly painful,  form  around  the  margin  of  the  opening, 
when  the  anus  is  involved. 

The  arms,  legs,  thighs,  flexures  of  the  joints,  and  the  gluteal 
folds,  are  the  seats  of  what  often  prove  to  be  stubborn  cases. 
These  parts  are  generally  affected  with  severer  forms  than  other 
portions  of  the  body,  are  accompanied  by  the  most  intolerable 
itching,  and  usually  pass  directly  from  the  erythematous  to  the 
pustular  stage,  where  they  linger. 

On  the  hands  or  feet  it  usually  presents  a  typical  course,  but 
often  becomes  fissured.  When  occurring  here  it  has  but  little 
exudation,  and  consequently  but  little  crusting.  The  most 
common  causes  of  eczema  of  the  hands  and  feet,  are  irritants 
acting  locally.  On  the  umbilicus,  there  is  considerable  edema  ; 
and  here  it  may  occur  in  the  pustular  or  severe  {e.  rubriwi) 
form.  In  young  children  and  those  not  old  enough  to  control 
the  tendency  to  scratch,  the  affected  portions  have  **  scratch 
marks  "  scattered  over  them  in  more  or  less  profusion. 


764  THE  DISEASES  OF  CHILDREN. 

Pathology. — Eczema  is  essentially  a  catarrhal  inflammation 
of  the  skin,  and,  when  not  due  to  a  local  irritant,  is  either  a 
central  or  peripheral  trophoneurosis. 

Diagnosis. — In  the  typical  course,  eczema  can  hardly  be  mis- 
taken for  other  skin  diseases ;  but  in  the  imperfect  or  irregu- 
larly developed  cases  the  differential  diagnosis  requires  skill  and 
study. 

The  erythematous  stage  is  often  confounded  with  erythema^ 
but  the  symptoms  brought  out  by  the  subsequent  course  of 
the  disease  will  decide  the  diagnosis. 

Herpes  and  scabies  have  a  close  resemblance  to  the  vesicular 
stage  of  eczema  ;  but  the  herpetic  vesicles  are  larger  and  appear 
mostly  on  the  face  and  genitals,  while  the  eczematous  vesicles 
are  distributed  irregularly  over  the  body  and  are  smaller.  The 
characteristic  of  scabies  is  the  nightly  aggravation  of  itching, 
which  is  absent  in  eczema  ;  and  the  presence  of  acari,  which 
rapidly  disappear  under  anti-parasitical  treatment,  will  dispel 
all  doubt  as  to  the  disease. 

In  the  crusting  stage  it  may  be  confounded  with  impetigo- 
contagiosa  and  tinea  favosa.  The  eczema  crusts  are  greenish- 
yellow  ;  the  crusts  of  tinea  favosa  are  sulphur-yellow  and  cup- 
shaped  ;  while  those  of  impetigo  contagiosa  are  superficial  and 
have  the  appearance  of  being  "  stuck  on." 

The  squamous  form  has  a  strong  likeness  to  pemphigus  folia- 
ceous,  seborrhea,  dermatitis  exfoliativa  and  psoriasis.  Seborrhea 
has  larger  scales  than  eczema,  and  they  are  oily.  Pemphigus 
foliaceous  starts  from  bullae,  and  has  thick,  parchment-like 
scales.  Large  scabs,  which  are  thin  and  easily  detached,  charac- 
terize dermatitis  exfoliativa,  and  the  surface  presents  a  glazed 
and  reddened  appearance  when  they  are  removed  ;  the  scabs  of 
psoriasis  are  white  and  are  not  formed  from  any  exudation. 

E.  pustulosum,  when  involving  the  scalp,  is  frequently  mis- 
taken for  the  syphilitic  eruption;  but  there  is  no  previous  his- 
tory of  syphilis,  and  the  foul,  sickening  odor,  so  characteristic 
of  the  specific  disease,  is  absent. 

Prognosis. — In  acute  cases  the  prognosis  is  always  good ;  but 
in  chronic  cases,  and  especially  those  in  which  the  mucous 
openings  are  involved,  it  should  be  most  carefully  and  dis- 
creetly guarded,  as  these  cases  are  so  long-lasting  and  difificult 
to  treat. 

Treatment. — As  before  stated,  eczema  is  rapidly  and  thor- 
oughly cured  by  a  vigorous  and  proper  treatment,  faithfully 
and  persistently  carried  out.  There  are  many  chronic  cases 
that  seem  to  bafifle  the  best  skill  of  the  physician,  and  yet  be 
prolonged  for  years  in  spite  of  treatment  intelligently  applied ; 
and  this  seeming  non-amenability  has  given   rise,  among  the 


E  CZEMA — TREA  TMEN  T.  765 

laity,  to  the  idea  that  chronic  eczema  is  incurable;  but  in  direct 
controversion  of  this  lay  opinion,  it  can  be  said,  positively,  that 
all  cases  of  eczema,  acute  or  chronic,  will  yield  to  the  proper 
treatment.  What  that  proper  treatment  is,  must  be  deter- 
mined by  the  study  of  the  personal  idiosyncrasies  of  the  indi- 
vidual subject,  for  one  case  will  rapidly  improve  under  simple 
local  treatment,  another  gradually  grow  worse  under  the  same 
measures,  until  they  are  substituted  by  constitutional  remedies, 
when  it  quickly  mends ;  while  still  another  will  show  no  im- 
provement under  these  measures  used  singly,  but  when  they 
are  combined,  a  rapid  change  for  the  better  is  noticeable.  While 
some  are  so  readily  amenable  to  the  simplest  local  treatment, 
and  others  yield  quickly  to  the  constitutional,  the  majority  of 
cases  are  seemingly  not  affected  by  either  used  singly  ;  but 
when  both  of  these  measures  are  combined,  a  rapid  and  perma- 
nent cure  will  generally  be  the  result. 

The  local  treatment  may  be  divided  into  two  classes — sooth- 
ing and  stimulating.  As  to  the  application  of  these  classes, 
intelligence  and  a  knowledge  of  the  results  to  be  obtained  from 
their  use,  are  required  ;  and  one  physician,  with  no  more  at  his 
command  than  simple  olive-oil  and  ordinary  housekeeper's  soft- 
soap,  can  accomplish  more,  where  these  agents  are  intelligently 
used,  than  can  another,  with  a  formidable  array  of  drugs  used 
without  a  knowledge  of  their  application  ;  and  the  great  car- 
dinal principle  in  the  use  of  these  measures  is,  to  soothe  acutely 
inflamed  surfaces,  and  stimulate  the  chronic,  dry,  scaly  skin. 
The  degree  of  irritation  should  always  be  governed  by  the  re- 
quirements of  the  individual,  for  no  two  cases  present  exactly 
similar  appearances,  and  no  set  rule  can  be  laid  down  for  them. 

In  using  soothing  applications,  the  crusts  must  be  removed, 
so  that  the  preparations  to  be  used,  can  come  in  actual  contact 
with  the  diseased  skin  itself.  In  many  cases,  the  crusts  are 
very  difficult  to  remove,  and  sometimes  great  skill  and  patience 
are  required  in  their  thorough  removal,  without  causing  the 
patient  too  much  discomfort.  Generally,  however,  the  appli- 
cation of  warm,  soft  water,  combined  with  gentle  friction,  will 
be  sufficient  to  thoroughly  cleanse  them  from  the  skin  ;  but 
frequently  some  crusts  are  too  hard  to  be  removed  in  this  man- 
ner, and  the  application  of  warm  olive-oil  will  soften  them  suffi- 
ciently to  be  washed  off  with  the  water ;  while  others  are  so 
difficult  as  to  require  the  use  of  sapo  viridis  (green  soap),  which 
effectually  removes  the  hardest  crusts,  and  in  addition,  the 
masses  of  dead,  epithelial  cells,  exudation,  and  other  debris, 
leaving  the  inflamed  skin  in  a  thoroughly  clean  condition,  ready 
for  the  soothing  effects  of  the  emollient  application,  and  the 
healing  process.     It  often  occurs,  especially  on  the  scalp,  that 


766  THE  DISEASES  OF  CHILDREN. 

the  crusts  are  interlaced  with  hairs,  and  their  removal  can  be 
accomplished  rapidly  and  painlessly  in  the  following  manner;, 
raise  one  corner  of  the  crust,  and  with  a  pair  of  sharp,  fine- 
pointed,  curved  scissors,  snip  the  hairs,  gradually  raising  the 
crust  and  cutting  the  hairs  until  it  is  entirely  freed ;  then  wash 
the  surface  of  all  remaining  extraneous  matter. 

After  the  surface  has  been  thoroughly  cleansed,  and  all  crusts 
and  scabs  softened  and  removed,  the  skin  should  be  immedi- 
ately anointed  with  some  soothing  preparation,  so  as  to  pro- 
tect the  raw  surface  from  all  atmospheric  irritation.  It  matters 
not  what  this  emollient  be,  just  so  long  as  it  fulfills  the  required 
conditions.  Olive-oil,  either  cold  or  warm,  is  the  most  common 
in  use,  and  is  also  the  most  simple.  Various  ointments  and 
oleates  have  been  used,  some  with  highly  gratifying  success, 
and  others  with  indifferent  results.  Some  patients  cannot  bear 
what  is  apparently  borne  with  benefit  by  others,  and  these 
emollients  should  be  used  according  to  the  various  individual 
requirements.  In  some  cases  with  slight  inflammation,  and  in 
which  the  exudation  is  the  principal  symptom,  equal  parts  of 
starch  and  oxide  of  zinc,  or  buckwheat  or  rye  flour  dusted 
over  the  affected  surfaces  frequently,  proves  very  beneficial. 
To  allay  the  intense  itching,  cloths  wrung  out  in  hot  water 
and  applied  over  the  parts,  or  the  application  of  a  mixture  of 
one  dram  of  carbolic  acid  and  an  ounce  of  glycerine  to  a  pint 
of  hot  water,  has  a  decided  anti-pruritic  action.  During  the 
first  and  second  stages,  peroxide  of  hydrogen,  diluted  with  one 
or  two  parts  of  water,  may  be  applied  with  almost  magical  ef- 
fect. In  cases  in  which  large  areas  are  involved,  great  care 
should  be  used  in  the  application  of  mercurial  and  other  oint- 
ments over  too  large  an  absorbing  surface,  as  severe  constitu- 
tional symptoms  may  arise,  much  to  the  annoyance  of  both 
the  patient  and  physician. 

When  a  chronic  case  presents  a  dry,  scaly,  indurated  and 
thickened  skin,  the  stimulating  treatment  is  indicated.  Such 
severe  irritants  as  green  soap,  soft  and  various  other  potash 
soaps,  etc.,  are  best  for  this  purpose,  and  frictions  with  these 
set  up  a  sub-acute  inflammation,  when  the  irritants  can  be  dis- 
continued, and  emollient  applications  used.  After  the  use  of 
the  irritants  the  following  will  prove  useful  in  many  instances  : 
Boil  one  dram  of  gelatin,  two  of  glycerin,  and  three  of  water 
until  the  gelatin  is  thoroughly  dissolved,  and  then  add  one 
dram  of  oxide  of  zinc.  When  required  for  use  this  should  be 
heated  and  quickly  applied  with  a  stiff  brush,  as  it  rapidly  hard- 
ens into  a  thin,  transparent,  flexible  scale.  An  ointment  com- 
posed of  one  dram  of  white  oil  of  birch  to  the  ounce  of  vaselin, 
has  proved  beneficial  in  stubborn  cases. 


B  CZEMA — TREA  TMEN  T.  767 

The  constitutional  treatment  can  also  be  divided  into  two 
classes,  ?yz>.,  hygienic  and  therapeutic  ;  and  the  hygienic  farther 
into  considering  separately  the  diet,  habits,  clothing  and  clean- 
liness, and  surroundings. 

In  the  feeding  of  an  infant,  regularity  of  diet  is  as  essential  to 
its  well-being  as  to  an  adult  ;  and  the  practice  of  nurses  and  moth- 
ers  putting  the  child  to  the  breast  every  time  it  cries,  is  to  be 
strongly  deprecated  ;  for  if  the  little  one  cries  very  much  it  is 
undoubtedly  sick,  and  if  it  be  troubled  with  indigestion,  the 
breast  every  ten  minutes,  or  fifteen,  or  even  every  half-hour  only 
aggravates  the  existing  trouble  ;  and  as  indigestion  is  the  cause 
of  many  cases  of  infantile  eczema,  it  is  plainly  evident  how 
great  should  be  the  care  concerning  the  regularity  of  the  diet, 
as  irregular  feeding  is  the  main  cause  of  indigestion  in  infants. 
In  many  cases  the  fault  lies,  not  with  the  irregularity  of  the 
feeding,  but  with  the  food  on  which  the  child  is  fed,  for  sometimes 
the  indigestion  is  merely  a  nervous  demonstration  of  hunger,  due 
to  the  deficient  quality  or  insufficient  quantity  of  the  food,  which 
sets  up  a  condition  of  malnutrition.  Or  it  may  be  that  improper 
food,  such  as  pastry,  pickles,  insufficiently  cooked,  starchy  mat- 
ters, tea,  coffee,  meat,  etc.,  are  given  to  the  child,  producing 
indigestion.  Frequently  anger,  fright,  joy,  or  some  other  in- 
tense mental  excitation,  or  even  errors  of  diet  in  the  mother  or 
nurse,  by  deteriorating  the  milk,  produce  a  deranged  digestion 
in  the  infant. 

Sometimes  the  physician  is  called  to  see  some  puny,  ill- 
nourished  infant,  whose  face  and  scalp  are  almost  one  solid 
mass  of  eczema.  What  are  the  surroundings  of  such  a  case  ? 
Rags,  dirt,  and  filth  ;  and  an  existence  in  a  filthy,  illy-ventilated 
room,  entirely  innocent  of  sunshine.  The  poor,  hard-worked 
mother  has  not  sufficient  vitality  to  furnish  the  necessary  qual- 
ity of  the  milk  for  the  demands  of  the  child,  and  her  purse  is 
too  slender  to  procure  the  required  artificial  food.  And  the 
cleanliness  of  the  child  is  also  neglected,  for  the  mother  cannot 
spare  the  time  to  devote  to  the  necessary  washings  and  changes 
of  clothing ;  and  thus,  in  illy-ventilated  and  poorly-lighted  sur- 
roundings, the  poor  little  sufferer,  reeking  in  its  own  excretions, 
lives  on  day  after  day,  through  a  tortured  and  miserable 
existence. 

From  the  above  it  is  plainly  evident  how  absolutely  necessary 
to  the  health  of  the  average  infant  is  regular  feeding,  proper 
food,  cleanliness,  and  good  hygienic  surroundings.  If  the  food 
is  irregularly  furnished,  fix  certain  hours  for  the  feeding  and  see 
that  they  are  observed.  When  the  child  is  nursing,  and  the 
milk  does  not  furnish  sufficient  nourishment,  the  mother's  or 
nurse's  diet  should  be  looked  after,  and  their  general  health  im- 


768  THE  DISEASES  OF  CHILDREN 

proved.  If  she  does  not  secrete  the  necessary  quantity  of 
milk,  some  good  artificial  food  should  be  given  the  baby  in 
addition  to  the  breast ;  or  if  the  child  be  old  enough,  and  the 
season  be  fall  or  winter,  it  should  be  weaned,  and  that  artificial 
food  which  best  answers  all  needs  of  its  system,  given.  If 
bottle-fed  and  insufficiently  nourished,  the  food  should  be 
changed  and  experimented  with  until  someone  is  found  that  will 
suffice.  If  the  bowels  are  constipated  or  in  adiarrheic  condition, 
or  the  kidneys  not  properly  performing  their  work,  they  should  be 
promptly  looked  after,  and  measures  adopted  that,  in  each  in- 
dividual case,  will  best  restore  them  to  their  normal  status. 
Where  improper  food  is  the  cause,  all  indigestible  foods,  as 
pastry,  pickles,  tea,  coffee,  and  the  various  nitrogenous  sub- 
stances are  to  be  prohibited ;  and  only  such  farinaceous  foods 
fed  as  will  meet  all  the  requirements  of  that  particular  infant. 
Often  the  mother  or  nurse,  after  undergoing  some  strong  men- 
tal or  nervous  excitement,  consoles  herself  by  putting  the  baby 
to  the  breast ;  but  this  should  not  be  done,  and  instead,  the 
breast-pump  should  be  used,  and  the  breasts  thoroughly  emp- 
tied of  their  poisoned  contents,  and  the  infant  not  allowed  to 
nurse  for  two  or  three,  or  even  four,  hours.  This  is  to  be 
strongly  insisted  upon,  for  any  woman  who  gives  her  child  the 
breast  after  severe  anger,  fright,  excessive  joy  or  grief,  or  any 
other  intense  mental  excitement,  runs  the  risk  of  causing  it  to 
have  indigestion,  or  seeing  it  thrown  into  convulsions,  often 
followed  by  speedy  death. 

Nor  should  the  bathing  be  neglected  ;  and  the  napkins  are  to 
be  changed  as  soon  as  soiled,  and  the  parts  washed  before  clean 
ones  are  replaced.  By  this  it  must  not  be  inferred  that  we  ad- 
vocate the  frequent  bathing  of  the  infected  areas,  but,  rather, 
bathing  for  reasons  of  bodily  cleanliness.  Instead  of  using 
harsh,  stiff,  linen  clothing  to  scratch  and  irritate  the  tender  skin, 
soft  flannels  should  be  the  material  employed  in  the  make-up 
of  the  wardrobe.  The  various  infant  powders  are  to  be  ban- 
ished, as  they  absorb  the  moisture  of  the  skin,  sour  and  cake, 
and  the  rough  edges  cut  the  delicate  cuticle  ;  and  instead  of 
these  preparations,  a  thin  slip  of  absorbent  cotton  should  be 
placed  between  the  folds  of  the  flesh  and  frequently  renewed  ; 
and  this  of  itself  will  in  some  cases  cure  an  intractable  eczema. 

When  the  physician  begins  to  treat  an  eczema  he  should  in- 
sist upon  his  instructions  being  carried  out  to  the  letter,  even  to 
his  becoming  dogmatic  ;  for  it  is  invariably  the  rule  that  the 
nurse  or  mother  will  only  half  obey  his  orders,  and  failure  fol- 
lows, which  will  be  damaging  to  his  reputation. 

In  considering  the  indications  for  the  remedies,  they  will  be 
found  to  be  both  numerous  and  varied.     A  large  percentage  of 


ECZEMA— REMEDIES.  769 

all  the  remedies  in  the  materia  medica  have  directly  or  indi- 
rectly some  decided  action  or  effect  on  the  skin,  and,  hence,  in 
a  work  like  this,  it  is  impossible  to  consider  all,  so  we  will  men- 
tion but  a  few  of  the  leading  ones. 

Ammonium  carb. — Eruption  dark  red  and  bleeds  easily;  in- 
tense pruritis  relieved  by  scratching,  but  followed  by  sensation 
of  burning  ;  nates,  genitals  and  anus  excoriated  and  painful ; 
especially  useful  in  eczema  of  flexures  of  joints. 

Arsenicum  alb. — Eruption  burning  and  itching,  painful  after 
scratching ;  crusts  are  surrounded  by  an  inflamed,  painful  border ; 
pain  and  pruritis,  worse  at  night  and  from  cold  and  scratching, 
but  better  from  warmth  ;  hair  falls  out ;  intense  thirst ;  useful 
in  chronic  cases  that  present  a  dry,  white,  parchment-like  skin, 
covered  with  fine  branny  scales. 

Calcarea  carb. — Eruption  covered  with  thick,  greenish-yellow 
crusts,  formed  from  the  gummy,  yellowish,  purulent  secretion ; 
intense  burning  pruritis,  worse  at  night  and  after  nursing,  bet- 
ter from  warmth  ;  painful  fissures  and  cracks  of  the  skin  ;  scalp 
most  commonly  involved  ;  useful  in  light-complexioned,  plump 
children  of  a  strumous  diathesis. 

Croton  tig. — Variable  appetite ;  sensation  of  water  in  abdo- 
men ;  stools  diarrheic,  thin,  watery,  green  mucus,  exceedingly 
offensive  and  forcibly  shot  out  of  rectum  ;  urine  high  colored 
and  fetid ;  face  covered  with  eruption  of  vesicles,  worse  in 
afternoon ;  intense  pruritis  aggravated  by  warmth  of  bed  at 
night,  better  in  morning  and  from  cold  ;  eruption  on  the  face 
and  genitals. 

Graphites. — Skin  dry  and  with  a  tendency  to  fissure,  the 
exudation  from  which  excoriates  the  surrounding  parts ;  the 
eruption  is  moist,  with  thick  crusts  situated  on  raw,  inflamed 
surfaces,  which  exude  a  thick,  corrosive,  sticky  serum ;  intense 
pruritis,  aggravated  from  scratching,  and  at  night ;  eruption  on 
the  palms  of  the  hands  and  behind  the  ears. 

Lappa  major. — Eczema  of  the  scalp  extending  to  the  face  ; 
moist,  bad-smelling  eruption  on  the  heads  of  children  ;  swelling 
and  suppuration  of  the  axillary  glands  ;  disposition  to  boils. 

Mercurius. — Skin  dirty  yellow  ;  eruption  involves  large  areas, 
which  itch  intolerably,  especially  when  warm  ;  exudation  of  a 
thin  serum,  which  forms  dry  scales,  or  an  acrid  discharge  burn- 
ing and  excoriating  the  skin,  and  drj'ing  into  yellow  crusts  ;  itch- 
ing and  bleeding  after  scratching  ;  tendency  to  lymphadenitis  ; 
profuse  perspiration. 

Mercurius precip.  ruber. — Pustular  eczema  about  anus,  geni- 
tals or  umbilicus;  pustules  on  inflamed  base  and  very  painful  to 
touch  ;  crusts  are  formed  from  the  yellowish  pustular  exudation, 
they  crack  and  from  these  fissures  the  pus  is  constantly  oozing. 
D.  C— 49 


770  THE  DISEASES  OF  CHILDREN' 

Oleander. — Oozing  behind  the/ ears,  and  on  the  back  of  the 
head  ;  smooth,  shining  surface,  covered  with  drops  of  serum  ; 
extreme  sensitiveness  of  the  skin  ;  even  the  friction  of  the 
clothing  causes  soreness  and  rawness. 

Rhus  tox. — Eruption  on  a  raw,  excoriated  surface,  exuding  a 
thin,  stickjT^,  offensive  serum,  which  forms  thick  crusts  ;  mostly 
on  face  and  scalp  ;  burning  and  itching,  worse  at  night. 

Stannum. — In  eczemas  due  to  the  presence  of  intestinal 
worms ;  child  is  very  irritable  and  excessively  hungry,  while 
every  meal  is  followed  by  nausea  and  vomiting ;  eczema  of 
lower  extremities. 

Sulphur. — In  the  vesicular  and  pustular  varieties,  with  burn- 
ing pruritis,  worse  at  night,  and  leaving  a  sense  of  soreness 
after  scratching ;  exudation,  a  fetid  pus  forming  thick  crusts 
which  bleed  easily. 

Viola  Tricolor. — Humid  eruption,  with  intolerable,  nightly 
itching ;  discharge  of  yellow  water  or  pus ;  swelling  of  the  cer- 
vical glands ;  eczema  on  the  face. 

Zinc  phos. — Especially  useful  in  eczemas  of  head  and  scalp, 
due  to  deranged  nervous  system  ;  trembling  and  jerking  of  the 
muscles ;  fidgety,  restless,  and  with  a  crawling  or  creeping  sen- 
sation over  body ;  pruritis  worse  during  afternoon  and  evening. 


CHAPTER  11. 

PSORIASIS  (psora — DRY   OR    SCALY  TETTER). 

Definition.  —  Psoriasis  is  a  constitutional,  non-contagious 
disease  of  the  skin,  characterized  by  dry,  reddish,  sHghtly  ele- 
vated patches,  covered  thickly  with  whitish  or  grayish,  mother- 
of-pearl  like,  imbricated  scales.  It  may  occur  on  any  part  of 
the  body,  but  is  especially  liable  to  appear  on  the  tips  of  the 
elbows,  fronts  of  the  knees,  just  below  the  patella,  on  the  hips 
and  on  the  head.  The  elbows  and  knees  are  oftener  affected 
in  females  than  in  males.  When  the  head  is  attacked,  the  erup- 
tion extends  beyond  the  margin  of  the  hair,  and  often  forms  a 
ring  around  the  forehead  and  ears.  The  back  is  more  commonly 
involved  than  the  chest.  The  nails  are  at  times  affected,  and 
the  free  margins  may  become  whitish,  thickened  and  friable. 
The  palms  and  soles  rarely  suffer.  A  sensation  of  itching  is 
sometimes  present  in  a  marked  degree,  but  as  a  rule  it  is  not 
troublesome. 

Etiology. — Psoriasis  seldom  appears  during  infancy,  but  may 
occur  at  any  age  after  three  years.  Heredity  seems  occasionally  to 
play  a  part  in  its  causation.  It  prevails  more  in  winter  than  in  sum- 
mer, and  in  many  cases  disappears  entirely  at  the  latter  season, 
to  return  with  the  advent  of  cold  weather.  While  a  few  cases 
may  appear  to  depend  upon  a  gouty  or  rheumatic  diathesis,  it  is 
a  singular  fact  that  a  great  majority  of  psoriatic  patients  often 
appear  to  be  the  picture  of  health.  In  predisposed  subjects 
debilitating  influences  may  precipitate  an  attack. 

Symptomatology. — The  lesions  invariably  begin  as  small,  red 
papules,  scarcely  raised  above  the  level  of  the  skin,  which 
quickly  become  covered  with  whitish,  imbricated  scales.  The 
scaly  papules  usually  increase  at  their  periphery,  and  form 
flattened  patches  varying  from  the  size  of  a  pea  to  two  or  more 
inches  in  diameter.  In  the  progress  of  the  disease  the  patches 
tend  to  run  together  as  they  increase  in  size,  and  their  circular 
outline  becomes  lost.  Occasionally  the  centers  of  the  patches 
clear  up  and  rings  or  festoons  are  formed.  As  the  discs  increase 
in  size,  the  skin  becomes  more  infiltrated,  and  the  scales  become 
large,  imbricated,  and  more  or  less  adherent.  When  scales  are 
removed  numerous  bright  red  dots — apices  of  hyperemic  pa- 
pillae— are  revealed,  which  are  easily  made  to  bleed. 

(771) 


772  THE  DISEASES  OF  CHILDREN. 

Various  designations  were  given  by  earlier  dermatologists  to 
the  different  clinical  appearances  presented  by  psoriasis  in  dif- 
ferent cases,  such  as  p.  punctata,  when  the  lesions  are  pin-head 
size  ;  p.  guttata,  when  the  discs  are  small  and  round,  and  have 
the  appearance  of  drops  of  mortar  scattered  on  the  skin  ;  /. 
nummularis,  when  the  discs  have  the  size  of  small  coins ;  /. 
diffusa,  when  the  patches  become  irregular  in  size  and  cover  a 
considerable  amount  of  surface ;  /.  annularis,  when  rings  have 
been  formed  by  the  patches  clearing  away  in  the  center,  while 
extending  upon  their  periphery ;  and  p.  gyraia,  when  these 
rings  join  each  other,  and  form  by  their  coalescence  broken 
semicircles,  or  graceful  festoons.  These  descriptive  names  must 
not  be  regarded  as  indicative  of  so  many  different  varieties  of 
the  disease,  but  simply  as  expressive  of  the  varying  forms  the 
eruption  may  assume  during  its  progress. 

Pathology, — Concerning  the  pathology,  the  process  is  sup- 
posed to  begin  as  a  hyperplasia  of  the  epithelial  cells,  and  the 
inflammatory  changes  in  the  corium  are  believed  to  be  second- 
ary to  it.  The  peculiar  whiteness  of  the  scales  is  due  to  the 
presence  of  air  between  the  dry,  epithelial  cells. 

Diagnosis. — The  diagnosis  of  psoriasis  in  well-marked  and 
typical  cases  is  generally  unattended  with  difificulty.  Atypic 
cases  are,  however,  sometimes  encountered  where  the  lesions 
bear  a  close  resemblance  to  those  of  eczema,  syphilis,  lupus 
erythematosus  and  dermatitis  exfoliativa.  In  eczema  there  is 
apt  to  be  a  history  of  moisture,  while  in  psoriasis  the  lesions  are 
invariably  dry  and  scaly.  The  scales  of  psoriasis  are  more 
abundant,  larger  and  whiter  than  those  of  eczema.  The  patches 
of  the  former  are  bold  and  well  defined,  while  those  of  the  lat- 
ter shade  off  into  the  healthy  skin.  Itching  is,  as  a  rule,  more 
pronounced  in  eczema  than  in  psoriasis.  A  squamous  syphilide 
may  be  mistaken  for  psoriasis.  In  the  latter  the  patches  ap- 
pear to  be  on  the  surface,  are  very  scaly,  and  have  a  bright-red, 
inflammatory  tint ;  while  in  the  former,  they  are  dull-red  or 
ham-colored,  deeply  indurated  and  only  scantily  covered  with 
scales.  Psoriasis  may  show  repeated  outbreaks  of  the  same 
kind  of  eruption,  while  in  squamous  syphilide  previous  eruptions 
will  have  been  of  a  different  type.  A  scaly  eruption  confined 
to  the  palms  and  soles  is  almost  without  exception  a  syphilide. 
Lupus  erythematosus  is  usually  found  upon  the  cheeks,  the 
scales  are  scanty  and  of  a  yellow  or  gray  color,  and  are  firmly 
attached  to  the  openings  of  the  sebaceous  glands.  In  derma- 
titis exfoliativa  the  suddenness  of  the  attack,  the  universality 
of  the  cutaneous  inflammation,  and  the  abundant  and  continu- 
ous exfoliation  of  dry,  thin,  papery  scales  are  sufficiently  pa- 
thognomonic. 


rSOBIASIS.  773 

Prognosis. — Psoriasis  is  one  of  the  most  rebellious  of  the 
inflammatory  diseases  of  the  skin.  The  prognosis  is  good  as  far 
as  any  one  individual  attack  is  concerned,  in  ordinary  cases. 
The  disease,  however,  is  prone  to  relapse  after  a  longer  or 
shorter  period.  Left  to  itself  it  may  run  a  variable  course,  con- 
tinuing for  months,  and  often  for  years,  or  occasionally  disap- 
pearing spontaneously. 

Treatment. — The  constitutional  treatment  of  psoriasis  is  of 
the  greatest  importance.  The  following  are  the  oftenest  indi- 
cated remedies: 

Arsenicum  iod. —  Persistent  itching  and  burning,  and  marked 
infiltration  ;  the  skin  is  dry  and  scaly,  and  pricking  sensations 
are  experienced  ;  useful  in  scrofulous  subjects. 

Arsenicum  sulph. — Irregularly  rounded,  reddish  spots,  cov- 
ered thickly  with  scales,  occurring  on  the  trunk,  knees,  elbows, 
and  hips,  attended  with  itching  and  burning;  adapted  to  ca- 
chectic subjects. 

Borax  veneta. — Psoriasis  on  the  face  and  scalp,  especially 
when  the  skin  displays  a  dingy,  unhealthy  look. 

Chrysarobinuni. — In  acute  cases  attended  with  itching,  and 
when  the  eruption  is  profuse  on  the  lower  extremities. 

Cinnabaris.  —  In  scrofulous  and  syphilitic  subjects,  or  when 
the  patches  are  irritable  and  of  a  fiery  red  color. 

Manganum. — In  inveterate  cases  and  in  rheumatic  and  gouty 
subjects. 

Mercurius  sol. — In  light-haired  people,  and  in  syphilitic  and 
scrofulous  individuals ;  the  scalp  is  frequently  painful  to  the 
touch,  and  dry,  scaly  spots  appear  all  over  the  body. 

Natrum  ars. — The  skin  is  dry  and  rough,  and  the  patches  are 
slightly  reddened  and  covered  with  thin,  whitish  scales  ;  patient 
is  sensitive  to  cold  and  becomes  easily  fatigued. 

Nitric  acid. — Dry,  scaly  skin,  with  stinging  sensation  in  the 
patches,  in  dark-haired  people. 

Petroleum. — Psoriasis  of  the  hands  and  scalp ;  painful  sensi- 
tiveness of  the  skin,  itching  worse  in  the  open  air. 

Silicia. — The  nails  are  brittle,  thickened  and  yellow. 

Sulphur. — Of  service  to  begin  treatment  with  ;  in  obstinate 
cases  to  eradicate  a  tendency  to  return. 

Local  measures  are  of  more  or  less  benefit,  according  to  the 
nature  of  the  case.  The  scales  may  be  removed  by  the  free 
use  of  soap  lotions,  alkaline  baths,  or  a  two-per-cent.  solution 
of  salicylic  acid  in  a  mixture  of  alcohol  and  castor-oil.  Marked 
success  follows  the  use  of  a  ten-per-cent.  solution  of  chrysaro- 
bin  in  liquor  guttapercha,  thinly  painted  on  the  affected  patches 
by  means  of  a  stiff  paint  brush,  and  renewed  every  two  or  three 
days.     On   delicate  skins  it  will  sometimes  produce  an  acute 


774  THE  DISEASES  OF  CHILDREN. 

dermatitis,  and  should  always  be  used  with  caution.  It  has  the 
disadvantage  of  staining  the  skin  temporarily.  Owing  to  the 
uncertainty  of  obtaining  a  good  quality  of  chrysarobin,  some 
dermatologists  prefer  a  five-per-cent.  solution  of  gun  powder, 
of  which  the  former  is  the  active  principle.  On  the  edge  of 
the  scalp  and  about  the  face  a  five-per-cent.  ointment  of  beta- 
naphthol  or  of  thymol  is  preferable  to  chrysarobin. 

A  radical  change  in  the  dietary  is  frequently  productive  of 
the  most  beneficial  results.  As  a  rule,  all  stimulating  fluids 
and  seasoned  articles  of  diet  should  be  avoided.  Some  cases 
are  markedly  benefited  by  entire  abstinence  from  nitrogenous 
foods,  while  others  steadily  improve  on  an  exclusive  beefsteak 
and  hot-water  diet. 


CHAPTER  III. 

MILIARIA  RUBRA — (RED   GUM,   STROPHULUS,  TOOTH-RASH). 

Definition. — Milaria  rubra  is  the  strophulus  or  red  gum  of 
older  writers,  and  is  very  common  among  infants,  particularly 
during  the  period  of  dentition.  It  is  characterized  by  an  erup- 
tion of  small  red  or  white  papules,  varying  in  size  from  a  pin's 
head  to  a  small  pea.  These  papules  are  due  to  a  congestion 
of  the  orifices  of  the  sweat  ducts,  and  appear  in  successive 
crops,  each  crop  remaining  from  ten  to  fourteen  days,  when 
it  disappears  and  a  new  crop  takes  its  place.  The  papules  are 
in  patches  of  a  dozen  or  more,  and  are  surrounded  by  an  erythe- 
matous border. 

Etiology. — The  principal  factor  in  the  causation  of  miliaria 
rubra  in  children,  is  dentition.  This  process,  when  accompanied 
by  abnormal  conditions,  is  highly  productive  of  it,  and  many 
cases  end  spontaneously  with  the  cessation  of  the  dental  irrita- 
tion. When  occurring  in  extreme  infancy,  it  is  a  result  of  a 
congestion  of  the  sweat-glands,  due  to  over-dressing,  warm 
weather,  and  the  rooms  in  which  the  child  is  kept  being  over- 
heated. Flea-bites  are  often  an  exciting  cause,  when  from  lack 
of  cleanliness,  these  little  pests  are  allowed  to  be  generated. 

Symptomatology. — The  principal  seats  of  the  eruption  are  on 
the  face,  neck  and  arms ;  although  it  may  be  distributed  over 
nearly  the  entire  body.  The  eruption  is  made  up  mostly  of 
papules,  which  are  raised  somewhat  above  the  surface,  their 
margins  are  sharply  outlined,  are  rounded,  pale  and  to  the 
touch  have  a  peculiar  hard  or  "  shotty  "  feeling.  In  the  center 
of  these  papules  is  a  semi-transparent  spot,  giving  the  papules 
the  appearance  of  a  vesicle,  but  on  being  punctured  no  fluid 
escapes. 

The  papules  usually  appear  over  considerable  extent  of  sur- 
face, generally  on  the  face  and  arms,  and  are  accompanied  by 
<:onsiderable  itching ;  and  as  they  are  scratched,  as  a  result  of 
the  itching,  numerous  fine  points  of  blood  are  exuded,  which 
dry  into  minute  scabs,  on  their  apices.  The  eruption  usually 
reaches  its  maximum  in  three  or  five  days ;  and  then,  unless 
prolonged  by  some  condition,  gradually  disappears.  In  infants 
of  a  scrofulous  diathesis,  the  papules  rapidly  undergo  suppura- 
tion and  form  pustules. 

(775) 


776  THE  DISEASES  OF  CHILDREN. 

Diagnosis. — Erythema  papulosum  is  the  only  disease  that 
can  be  confounded  with  miliaria  rubra ;  and  the  two  can  be 
readily  differentiated  by  the  severe  constitutional  disturbances 
of  eczema,  and  the  exceedingly  mild,  and  lack  of  constitutional 
symptoms  of  miliaria  rubra. 

Prognosis. — Miliaria  rubra  is  a  mild  disease,  and  of  itself  is 
never  fatal.  If  severe  symptoms  are  present,  they  are  due  to 
some  complication. 

Treatment. — About  the  only  treatment  required  is  hygienic, 
as  internal  medication  is  seldom,  if  ever,  indicated.  The  diet 
is  to  be  carefully  attended  to,  and  the  bowels  regulated.  If 
the  gums  are  swollen  and  tender,  causing  much  discomfort, 
they  should  be  freely  incised.  Strict  attention  should  be  paid 
to  the  cleanliness  of  the  child  and  all  unnecessary  articles  of 
clothing  should  be  forbidden  to  be  put  on. 

Antimonium  crudum,  apis  vtel.,  borax,  calc.  carb.,  chamomilla, 
etc.,  may  be  given  as  indicated,  but  in  the  majority  of  cases,  no 
remedies  are  required. 


CHAPTER  IV. 

ERYTHEMA    (ROSE    RASH.) 

Definition. — Erythema  is  an  inflammatory  condition  of  the 
skin,  characterized  by  an  eruption  of  tubercles,  macula  or 
papules,  accompanied  by  a  varied  degree  of  pruritis  and  burn- 
ing. 

It  is  acute,  non-contagious  and  non-specific  in  character,  and 
usually  runs  its  course  in  a  few  hours,  or  at  most  four  or  five 
days.  Its  principal  symptom  is  an  hyperemia  which  appears 
very  suddenly  on  the  surface,  and  is  irregular,  in  outline  and 
of  variable  extent.  The  eruption  on  first  appearing  is  of  a 
bright-red  color,  which  gradually  changes  to  a  bluish  tint.  At 
first  there  is  usually  neither  swelling  nor  hypersensibility  ;  but 
with  the  progress  of  the  symptoms  the  bluish  deepens  to  a  dark 
rose-red,  the  skin  becomes  extremely  sensitive,  indurated  and 
oftentimes  fissured,  while  in  neglected  cases  it  may  become 
ulcerated. 

While  erythema  means  a  redness  or  hyperemia,  the  defini- 
tion of  the  term  is,  more  strictly  speaking,  a  symptom  ;  and  it 
often  occurs  in  the  course  of  diseases,  especially  of  the  exanthe- 
mata. Properly  treated  in  its  incipency,  erythema  is  usually 
very  simple. 

Etiology. — When  occurring  on  the  skin  of  a  new-born  infant^ 
it  is  usually  a  mild  cutaneous  congestion,  due  to  the  change 
from  the  influence  of  the  womb  during  fetal  life  to  the  atmos- 
pheric irritation  immediately  after  birth,  and  requires  no  treat- 
ment as  long  as  it  remains  a  simple  hyperemia. 

The  causes  of  this  affection  may  be  divided  into  two  classes, 
viz.:  idiopathic  and  symptomatic.  The  idiopathic  are,  extremes 
of  heat  and  cold  ;  rapid  and  excessive  changes  in  the  weather ; 
hot  weather ;  too  frequent  bathing ;  frictions  from  towels  and 
strong  soaps  ;  insufficient  bathing ;  fecal  and  urinary  matters  on 
soiled  napkins  ;  pressure  from  stiff  and  tight  clothing  and  shoes, 
instruments,  such  as  trusses,  braces,  etc.;  burns  and  scalds.  The 
symptomatic  cases  generally  occur  as  a  symptom  of  some  inter- 
nal disease,  as  scarlet  fever,  measles,  etc. 

Varieties. — Early  writers  divided  this  affection  into  classes, 
according   to   the   extent  of  surface   involved  and  the   shape 

(777) 


778  THE  DISEASES  OF  CHILDREN. 

assumed  by  the  eruption  ;  but  this  classification  is  entirely  use- 
less, as  these  manifestations  are  but  the  various  stages  of  the 
disease  and  not  separate  or  distinct  varieties.  There  are,  how- 
ever, different  varieties  according  to  the  character  of  the  erup- 
tion ;  and  we  shall  confine  ourselves  to  the  three  forms  con- 
cerned in  childhood,  and  they  are  :  erythema  simplex,  erythema 
intertrigo  and  erythema  nodosum. 

Symptomatology — Erythema  simplex. — The  simple  form  of 
erythema  usually  occurs  during  the  course  of  the  acute  internal 
inflammatory  diseases  ;  mostly,  however,  during  the  course  of 
those  depending  on  the  period  of  dentition.  It  often  occurs 
during  a  high  fever  from  any  cause,  and  especially  in  those 
children  having  an  active  cutaneous  circulation.  The  first 
symptom  is  the  appearance  of  slightly  reddened  patches,  more 
or  less  numerous,  and  of  different  shape  and  extent,  accom- 
panied by  a  greater  or  less  degree  of  pruritis.  The  color  dis- 
appears on  pressure,  but  rapidly  returns  on  the  removal  of  the 
pressure.  There  is  no  swelling,  infiltration  or  fissuring  of  the 
skin,  and  as  the  rash  becomes  older,  its  color  deepens.  After 
the  disease  has  run  its  course,  the  cutaneous  symptoms  disap- 
pear, and  the  eruption  usually  ends  in  desquamation. 

Erythema  intertrigo. — This  form  usually  attacks  the  folds  of 
the  skin  about  the  nates,  hips,  anus,  arms,  neck,  flexures  of  the 
joints,  inner  aspect  of  the  thighs,  and  the  genitals.  Here  it 
begins  as  a  simple  redness,  and  when  neglected,  generally  runs 
into  a  true  eczema.  In  severe  cases,  there  is  ulceration,  the 
surface  presenting  a  raw,  deep-red,  and  angry  appearance  ;  from 
which  a  serous  or  sero-purulent  exudation,  very  fetid  and  acrid, 
is  discharged,  accompanied  by  severe  pruritis,  burning  and  pain. 
When  the  ulceration  has  ceased,  red  or  copper-colored  spots 
mark  the  site  of  the  ulcers,  and  are  very  slow  in  disappearing. 
If  slight,  this  form  will  last  but  a  few  days,  while  aggravated 
cases  may  be  prolonged  for  months. 

Erythema  fwdosum. — Is  the  variety  that  generally  occurs 
singly,  but  is  sometimes  accompanied  by  one  of  the  other 
forms.  It  shows  a  preference  for  the  anterior  portion  or  ex- 
tensor aspect  of  the  arms  and  legs,  although  it  may  be  found 
on  other  portions  of  the  body.  Its  chief  characteristic  is  an 
eruption  of  small,  painful  spots  or  nodositers,  which  gradually 
increase  in  size.  They  vary  in  size  from  a  pinhead  to  a  split 
pea  and  never  suppurate.  After  they  begin  to  swell,  the  skin 
becomes  tender  to  touch,  stretched,  and  finally  so  tense  as  to 
interfere  with  the  movements  of  the  member,  and  causes  great 
pain.  In  a  few  days  the  swelling  diminishes,  the  tension  less- 
ens, and  the  pain  subsides  until  it  finally  ceases  altogether. 
The   eruption  of  the  nodules  is  ushered    in  with  a  variable 


ERTTHEMA   {ROSE  RASH).  779 

degree  of  fever  and  general  malaise.  It  usually  develops  rapidly 
and  runs  an  acute  course. 

Diagnosis. — Simple  erythema  is  very  close  in  its  resemblance 
to  scarlet  fever  and  erysipelas.  From  scarlet  fever  it  can  be 
differentiated  by  its  accompanying  some  other  disease,  its 
limited  area,  short  course,  light  color,  absence  of  throat 
symptoms,  and  only  the  superficial  cutaneous  strata  being 
involved. 

From  erysipelas,  the  diagnosis  is  somewhat  harder,  and 
requires  more  skill.  Erysipelas  has  swelling,  smarting  and 
burning;  it  involves  the  deeper  layers;  its  margins  are  well  de- 
fined and  slightly  elevated  ;  and  it  progresses  slowly  to  new 
areas ;  while  erythema  suddenly  appears  on  one  spot,  and  in  a 
few  hours,  or  days,  as  suddenly  disappears  ;  there  is  no  swelling 
or  smarting,  some  pruritis  and  burning ;  it  involves  only  the 
superficial  layers,  and  its  margins  gradually  merge  off  into  the 
normal  color. 

Erythema  intertrigo  is,  in  most  cases,  easily  recognized,  but 
may  sometimes  be  mistaken  for  eczema,  as  there  are  so  few 
diagnostic  points  to  differentiate  by ;  and  while  the  intertrigo 
may  become  an  eczema,  the  chief  point  of  difference  is  the  in- 
filtration of  the  skin,  which  is  entirely  lacking  in  the  erythema, 
and  when  present  is  indicative  of  eczema. 

Erythema  nodosum,  when  occurring  on  the  anterior  aspect  of 
the  leg,  is  at  first  glance  mistaken  for  a  series  of  bruise  marks,  but 
the  absence  of  any  history  of  violence  decides  against  trauma- 
tism. It  has  many  features  in  common  with  syphilitic  gum- 
mata,  but  its  more  acute  course  will  differentiate.  Boils  and 
abscesses  are  smaller,  lighter  colored  and  suppurate  ;  while 
erythema  nodules  are  larger,  darker  colored  and  never  suppu- 
rate under  any  circumstances,  but  disappear  by  absorption. 

Prognosis. — In  the  majority  of  cases,  the  prognosis  is  good, 
as  the  disease  tends  to  a  spontaneous  termination  ;  but  when  it 
occurs  in  children  suffering  from  intestinal  troubles,  as  entero- 
colitis, colitis,  thrush,  etc.,  the  prognosis  should  be  guarded,  as 
these  cases  are  liable  to  end  fatally,  especially  when  involving 
an  intertrigo. 

Treatment. —  Simple  erythema  requires  no  treatment  for  it- 
self, but  the  whole  attention  of  the  physician  should  be  directed 
to  the  disorder  which  occasioned  it.  Usually,  in  the  intertrigo, 
strict  cleanliness,  regulation  of  the  bowels,  separating  the  over- 
lapping folds  and  keeping  them  separated,  the  application  of 
some  powder,  as  lycopodium,  equal  parts  of  starch  and  oxide 
of  zinc,  etc.,  or  zinc  ointment,  and  the  internal  administration 
of  the  indicated  remedy  will  be  followed  by  prompt  improve- 
ment.    In  erythema  nodosum,  the  best  treatment  is  rest  in  bed, 


780  THE  DISEASES  OF  CHILDREN. 

hot  applications  and  compresses  of  hamamelis,  a  good  gener- 
ous diet,  regulation  of  the  bowels  and  the  indicated  remedy. 

The  remedies  are  indicated  as  follows : 

Aconite. — Fever;  thirst;  restlessness;  skin  red,  hot,  swollen, 
shining  and  painful ;  worse  at  night. 

Arsenicum. — Intense  thirst;  great  pain  ;  burning  and  itching 
of  the  skin,  worse  after  scratching ;  ulcers  dark  and  angry ; 
exudation  very  fetid  and  excoriating. 

Belladonna. — Face  flushed  ;  head  hot ;  skin  exquisitely  pain- 
ful to  touch  ;  inflamed  red  patches,  breaking  out  irregularly 
over  the  body,  but  mostly  on  face  and  neck ;  smooth,  scarlet 
redness  of  the  skin. 

Chelidonium. — Prostration  ;  sleepiness ;  large,  red,  round 
patches  on  arms  and  face  ;  burning  pain  and  pruritis  ;  spots  dis- 
appear in  a  few  hours. 

Lactic  acid. — Debility ;  aversion  to  motion,  wants  to  lie  still  ; 
bright-red  spots  or  patches  on  different  parts  of  the  body,  es- 
pecially anterior  portion  of  thighs  and  legs. 

Nux  vomica. — Alternate  diarrhea  and  constipation  ;  general 
debility,  with  trembling  of  the  limbs  ;  eruption  dark,  painful 
and  intensely  pruritic. 

Rhus  ven. — Red  spots  from  half  an  inch  to  two  inches  in  di- 
ameter, especially  on  the  legs  below  the  knees,  painful  and 
changing  color  into  bluish,  then  greenish-yellow. 

Ustilago. — Eruption  very  fine  and  of  a  deep-red  color ;  spots  or 
nodules  about  the  size  of  a  pinhead,  very  painful  and  aggra- 
vated by  scratching ;  eruption  assumes  an  annular  form  when  it 
occurs  on  face  or  neck. 


CHAPTER  V. 

ZOSTER  (herpes   ZOSTER,  ZONA,   SHINGLES). 

Definition. — Zoster  is  an  acute,  non-contagious,  non-specific 
inflammation  of  the  skin,  characterized  by  an  eruption  of  vesicles 
which  follow  the  course  of  some  cutaneous  nerve  or  nerves, 
and  accompanied  by  an  acute  neuralgic  pain.  These  vesicles 
appear  in  groups,  which  vary  in  size  and  shape,  on  an  inflamed 
surface,  while  between  the  groups,  the  skin  is  healthy  in  color, 
appearance  and  function. 

It  is  a  self-limited  disease,  and  usually  runs  its  course  in  from 
ten  to  twenty  days ;  and  is  accompanied  by  few,  if  any,  severe 
constitutional  symptoms.  It  has  no  particular  part  to  which 
it  is  confined,  but  may  occur  on  any  portion  of  the  skin.  It  is 
met  with  most  frequently  involving  the  intercostal  nerves,  and 
when  it  occurs  here  it  is  known,  in  popular  parlance,  as  shingles. 

There  is  a  widespread  opinion  among  the  laity  that  shingles 
would  speedily  prove  fatal,  if,  when  occurring  on  both  sides,  it 
should  meet  and  form  a  complete  circle  around  the  body  ;  but 
the  fallacy  of  this  is  at  once  apparent,  for  zoster  involves  the 
course  of  the  nerves,  and  as  the  nerves  do  not  encircle  the  body, 
the  two  approaching  borders  can  never  coalesce. 

Zoster  occurs  with  equal  frequency  in  both  sexes,  and  is 
oftenest  observed  in  individuals  under  twenty  and  over  forty 
years  of  age.  It  is  rare  in  infants,  and  is  most  frequently  seen 
in  children  between  the  ages  of  five  and  thirteen. 

Etiology. — The  unvarying  rule  of  the  eruption  of  zoster  follow- 
ing the  course  of  a  nerve,  would  suggest  some  connection  with 
the  nerve  so  followed ;  and  it  is  in  most  cases  dependent  upon 
some  inflammatory  condition  of  that  nerve.  Thus  it  will  be 
seen  that  it  is  of  nervous  origin.  A  careful  study  of  those  who 
are  affected  with  it  would  reveal  the  fact  that  the  majority  have 
a  thin  and  delicate  skin. 

The  exciting  causes  are  all  those  causes,  which,  acting  upon 
the  cutaneous  nerves,  produce  a  neuritis  of  them,  and  they  are  : 
pressure,  burns,  wounds,  cuts,  bruises,  or  traumatism  of  any 
kind  ;  and  this  inflammation  or  neuritis,  in  connection  with  the 
requisite  predisposition,  will,  in  most  cases,  be  followed  by  an 
eruption  of  zoster. 

(781) 


782  THE  DISEASES  OF  CHILDREN. 

Symptomatology . — Zoster  resembles  the  eruptive  fevers,  in 
that  it  is  preceded  by  a  prodromal  period,  and  the  length  of 
this  period  is  unknown.  The  prodromal  symptoms  are :  more 
or  less  itching  along  the  track  of  the  inflamed  nerve,  neuralgic 
pain  of  greater  or  less  intensity,  fever,  restlessness,  loss  of  ap- 
petite and  intestinal  irritation.  Three  or  four  days  after  these 
symptoms  are  noticed,  the  eruption  makes  its  appearance  in  the 
form  of  fine  vesicles  situated  on  patches  of  inflamed  skin. 
These  inflamed  patches  vary  in  size  and  shape  ;  they  may  be 
about  the  size  of  a  silver  half-dollar  or  as  large  as  a  small  saucer, 
while  between  these  inflamed  areas  the  skin  remains  normal. 

In  children,  in  the  so-called  infantile  zoster,  there  is  seldom 
any  neuralgia,  and  the  only  disturbance  which  may  be  noted  is 
the  zosterian  fever,  with  some  gastric  distress. 

The  vesicles,  at  first,  are  fine  and  transparent,  being  filled 
with  a  clear,  colorless  serum ;  but  in  a  few  days  they  increase 
in  size,  lose  their  transparency,  and  become  yellow  and  turbid. 
They  last  from  seven  to  twelve  days,  and  if  their  contents  have 
not  been  evacuated,  they  either  dry  up  after  the  serum  has 
been  absorbed,  or  else  form  little  scabs,  which  soon  fall  off. 

When  the  vesicles  have  disappeared,  the  red  and  inflamed 
patches,  by  a  gradual  subsidence  of  the  redness  and  inflamma- 
tion, soon  return  to  their  normal  color  and  condition.  For 
some  time  after  the  skin  has  regained  its  normal  condition, 
there  still  remains  the  acute  neuralgic  pain,  though  less  in  se- 
verity, and  this  pain  is  very  annoying  until  it  finally  disappears. 
The  eruption  may  appear  simultaneously  at  the  opposite  ends 
of  the  nerves,  and  by  successive  formation  of  new  vesicles  and 
patches,  gradually  approach,  until  they  finally  coalesce.  It 
rarely  appears  a  second  time  in  the  same  subject,  one  attack 
generally  securing  complete  immunity  against  another. 

Diagnosis. —  Zoster,  from  its  characteristic  symptoms,  can 
hardly  be  mistaken  for  any  other  skin  disease,  but  it  is  some- 
time confounded  with  herpes,  and  may  be  differentiated  as  fol- 
lows :  herpes  has  a  tendency  to  recur  and  generally  appears  on 
both  sides ;  zoster  rarely,  if  ever,  appears  twice  in  the  same 
subject,  and  is  usually  unilateral ;  herpes  follows  in  the  wake 
of  some  catarrhal  affection  of  the  mucous  membranes,  and  in 
most  cases,  is  confined  to  the  face  and  genitals  ;  zoster  is  due 
to  some  neuritis,  and  follows  the  course  of  some  nerve  or 
nerves  ;  herpes  is  preceded  and  accompanied  by  a  burning  itch- 
ing, and  never  leaves  cicatrices ;  zoster  is  attended  by  a  more 
or  less  severe  neuralgic  pain,  and  often  leaves  scars  to  mark  the 
site  of  the  eruption. 

Prognosis. — As  zoster  is  not  of  itself  a  dangerous  or  fatal 
disease,  the  prognosis  is  always  favorable.     Children  usually 


ZOSTER.  783 

recover  rapidly,  and  neuralgia,  even  if  present  during  the  at- 
tack, is  seldom  persistent,  as  it  is  apt  to  be  in  adults  and  espe- 
cially in  the  aged. 

Treatment. — The  first  indication  in  the  treatment  of  zoster 
is  the  alleviation  of  the  pain,  and  this  is  best  accomplished  by 
the  use  of  the  galvanic  current.  The  current  should  be  used 
as  strong  as  can  be  borne,  or  about  six  cells,  and  should  be  ap- 
plied from  ten  to  fifteen  minutes  daily.  The  local  treatment 
consists  of  protecting  the  vesicles  from  external  irritation,  by 
coating  them  with  flexible  collodion  or  traumaticin,  cantharides 
ointment,  or  dusting  over  them  equal  parts  of  starch  and  sub- 
nitrate  of  bismuth,  and  then  over  this  applying  a  roller  band- 
age. 

The  indications  for  the  remedies  are  as  follows : 

Rhus  tox. — Sleeplessness,  with  restless  tossing  about ;  vesicles 
are  confluent,  small,  painful,  burning  and  surrounded  by  red 
skin  ;  pain  aggravated  by  scratching ;  worse  in  cold  weather ; 
disease  brought  on  by  getting  wet  while  overheated. 

Arsenicum. — Intense  burning  pain;  vesicles  confluent  and 
very  small;  intense,  cutting,  burning  neuralgia;  great  thirst 
and  exhaustion  ;  aggravated  at  night  and  by  cold  applications. 

Graphites. — Skin  dry  and  with  a  tendency  to  ulcerate;  large 
vesicles  following  course  of  intercostal  nerves;  burning  when 
touched,  and  worse  from  warmth ;  zoster  of  left  side. 

Mercurius. — Vesicles  involving  greater  part  of  one  side  of 
abdomen,  especially  the  right ;  tendency  to  suppuration ;  ag- 
gravation at  night,  and  from  warmth  of  bed. 

Zinc. — Acute  neuralgic  pains ;  aggravation  at  night  and  after 
eating ;  better  from  being  handled. 

Zinc  phos. — After  other  remedies  have  failed,  often  works 
wonders. 


CHAPTER  VI. 

ERYSIPELAS  (ST.  ANTHONY'S  FIRE). 

Definition. — Erysipelas  is  an  acute,  contagious,  specific  in- 
flammation of  the  skin  and  subcutaneous  connective  tissue, 
characterized  by  an  eruption  or  deep-red  rash,  accompanied  by 
a  pecuHar  pungent,  burning  pain,  and  heat  and  swelling.  A 
great,  or  marked,  characteristic  of  erysipelas  is  its  tendency  to 
spread  and  infect  other  portions,  the  primary  seat  healing, 
while  the  newly  invaded  surface  is  becoming  affected.  The 
disease  is  variable  both  as  to  its  extent  and  severity  ;  and  ac- 
cording to  its  extent  and  severity,  it  will  terminate  in  resolu- 
tion, suppuration  or  gangrene. 

It  is  rarely  ever  met  with  in  childhood,  and  when  such  cases 
are  seen  they  present  no  differences,  or  at  least  have  nearly  the 
same  features,  as  the  disease  when  occurring  in  adults;  but  on 
the  other  hand  it  is  a  common  affection  during  infancy,  espe- 
cially common  in  infants  under  six  months  of  age ;  for  in  forty 
consecutive  cases  occurring  in  infants,  twenty-seven  were  under 
six  months,  eight  between  six  and  twelve  months,  and  the  re- 
maining five  over  twelve  months.  The  disease  as  seen  during 
this  period,  presents  quite  a  number  of  distinctive  features  that 
differ  materially  from  that  which  occurs  in  adult  life. 

It  is  seldom  met  with  in  families  in  easy  circumstances,  but 
is  very  common  among  the  poor,  where  proper  attention  is  not 
devoted  to  the  requirements  of  cleanliness ;  and  in  crowded 
houses,  especially  in  lying-in  hospitals,  children's  homes  and 
foundling  asylums. 

The  course  of  the  disease  is  often  irregular,  and  the  physician 
may  be  priding  himself  on  the  apparent  success  of  his  treat- 
ment, when  suddenly  it  will  break  out  again  with  renewed 
vigor,  reinfecting  the  lately  healing  parts,  set  up  a  more  viru- 
lent inflammation  than  before,  and  speedily  carry  off  the  pa- 
tient from  exhaustion.  Thus  it  will  be  seen  that  one  attack 
is  no  security  against  another,  but,  rather,  leaves  the  system 
in  a  debilitated  state  that  is  susceptible  to  a  reinfection  of  the 
disease. 

In  the  adult,  the  favorite  point  of  infection  is  undoubtedly 
the  head  or  face,  while  in  infancy  they  are  seldom  starting- 
(784) 


ERTSIPELAS  {ST.  ANTHONY'S  FIRE).  785 

points.  In  thirteen  out  of  twenty-six  cases  occurring  in  female 
children,  the  point  of  invasion  was  the  vulva,  while  in  fifty- 
eight  cases  of  both  sexes,  thirty-four,  or  sixty  per  cent.,  the 
vaccination  site  was  the  commencement,  and  from  this  it  is  evi- 
dent that  the  vulva  and  vaccine  pocks  are  the  favorite  places 
of  invasion,  while  the  male  genitals  are  rarely  the  beginning,  as 
are  also  the  arms,  legs,  nates  and  feet. 

Etiology. — Erysipelas  must  be  regarded  as  a  specific  disease, 
inasmuch  as  it  depends  upon  the  entrance  into  the  system  of  a 
specific  micro-organism,  called  the  Streptococcus  erysipelatis. 

This  pathogenic  micro-organism  spreads  by  the  lymphatic 
channels  of  the  skin,  penetrates  into  the  tissues,  forms  chains 
or  swarms  of  cocei,  and  excites  a  specific  inflammation  and 
leads  to  tissue  necrosis. 

The  causes  that  favor  the  development  of  erysipelas  have  by 
common  consent  been  divided  into  two  classes,  viz.:  predispos- 
ing and  exciting. 

The  most  powerful  predisposing  cause  of  this  malady  in  the 
abstract  is  traumatism.  It  is  mostly  a  disease  of  the  temperate 
zone,  and  occurs  more  frequently  in  the  colder  than  in  the 
warmer  months  of  the  year.  It  is  particularly  prevalent  in 
damp,  changeable  weather,  with  unstable  temperature. 

Uncleanliness  and  improper  food,  living  in  damp,  dark, 
crowded  and  illy-ventilated  rooms,  and  especially  overcrowding 
in  hospitals,  as  during  the  existence  of  other  epidemics,  furnish 
conditions  favorable  to  the  development  of  the  disease.  It 
spreads  for  the  most  part  by  direct  contagion,  and  when  once 
established  in  a  house  or  in  a  public  institution,  it  may  develop 
upon  even  the  most  trivial  break  of  the  surface — abrasions,  fis- 
sures, etc. — in  susceptible  individuals. 

Vaccination  is  one  of  the  most  prolific  of  the  exciting  causes, 
and  often  the  abrasion  and  the  inflammation,  which  necessarily 
arise  around  the  point  of  operation,  are  the  cause  of  it,  and  not 
any  deleterious  quality  contained  in  the  virus,  as  is  supposed 
by  many  ;  and  this  is  well  borne  out  by  the  fact  that  the  in- 
flammation involving  a  burn  or  wound,  may  be  followed  by 
similar  results.  In  children,  on  account  of  the  difficulty  of 
dressing  and  caring  for  operations,  the  wounds,  in  most  vac- 
cinations, are  followed  by  some  degree  of  erysipelatous  inflam- 
mation. 

When  occurring  in  the  very  young,  it  is  principally  associ- 
ated with  the  separation  of  the  cord.  It  often  follows  closely 
upon  some  other  inflammatory  condition  of  the  surface,  as  the 
irritated  folds  of  the  skin  in  intertrigo,  etc.,  or  when  the  thin 
portions  of  the  cuticle  are  fissured,  as  at  the  corners  of  the  eyes, 
nostrils,  mouth,  arms  and  vulva.  Arnica,  rhus  tox.,  belladonna, 
D.  C— 50 


786  THE  DISEASES  OF  CHILDREN. 

and  other  drugs,  whether  used  externally  or  internally,  will,  if 
used  in  sufficiently  large  doses,  set  up  an  attack  of  this  disease. 
From  the  greater  percentage  of  cases  that  have  their  origin  at 
or  near  the  vulva,  it  may  be  readily  inferred  that  female  chil- 
dren are  more  liable  to  it  than  the  male. 

In  his  "  Treatise  on  Diseases  of  Children,"  Dr.  Condie  says 
of  the  connection  of  puerperal  fever  and  erysipelas :  "  Erysip- 
elas of  infants  very  commonly  occurs  during  the  prevalence  of 
epidemic  puerperal  fever.  Children  of  mothers  who  become 
affected  with  the  fever  are  often  born  with  erysipelatous  in- 
flammation ;  others  are  attacked  almost  immediately  after  birth. 
Whether,  in  these  cases,  the  disease  is  to  be  referred  to  a  mor- 
bid matter  applied  to  the  skin  in  the  womb,  or  to  the  same  ep- 
idemic or  endemic  influence  which  gives  rise  to  the  disease  of 
the  patient,  it  is  difficult  to  say.  According  to  M.  Trousseau, 
infantile  erysipelas  is  principally  observed  when  puerperal  fever 
prevails  in  the  wards  of  the  lying-in  hospitals  in  Paris." 

In  private  practice,  few  cases  of  infantile  erysipelas,  associ- 
ated with  erysipelas  in  the  mother,  are  met  with,  but  when 
puerperal  fever  and  erysipelas  are  epidemic  it  occurs  more  fre- 
quently. 

That  the  disease  is  spread  by  carelessness  in  the  handling  of 
infected  subjects  and  the  dressings,  direct  contagion  and  inoc- 
ulation, is  well  known  ;  and  as  the  disease  is  so  highly  contagious,, 
all  patients  suffering  from  it  should  be  isolated  as  much  as  pos- 
sible, the  dressings  and  bandages  destroyed  immediately  after 
removal,  and  the  nurse  should  disinfect  herself  before  coming 
in  contact  with  other  members  of  the  family. 

Symptomatology. — Infantile  erysipelas  is  in  some  cases  pre- 
ceded by  an  incubative  stage,  but  these  are  few  in  number, 
and  this,  with  the  lack  of  facilities  for  observation,  makes  it  al- 
most impossible  to  determine  the  length  of  this  stage.  It  is 
usually  ushered  in  with  slight  rigors,  drowsiness,  or,  in  some 
cases,  extreme  restlessness,  twitchings  of  the  flexor  and  exten- 
sor muscles,  increased  temperature,  rapid  pulse,  and  sometimes, 
nausea  and  vomiting.  With  the  onset  of  the  eruption  all  the 
symptoms  intensify  ;  and,  in  the  majority  of  cases,  there  is  ex- 
treme restlessness  caused  by  the  peculiar  pungent,  burning  pain 
accompanying  it.  When  it  appears  the  fever  increases,  some- 
times as  high  as  104°  or  105°,  or  even  106°,  pulse  very  rapid, 
often  160  to  180  per  minute  ;  there  is  considerable  thirst,  stom- 
ach is  irritable,  bowels  irregular  and  frequently  in  a  diarrheic 
condition,  the  face  is  flushed,  the  entire  cutaneous  surface  is 
hot  to  the  touch,  the  tongue  is  furred,  and  sleep  is  impossible 
from  the  burning  pain.  In  the  severe  cases  convulsions  have 
been  observed,  but  as  a  rule  they  do  not  occur. 


ERTSIPELAS  (ST.  ANTHONY'S  FIRE).  787 

If  it  occurs  at  or  near  the  umbilicus,  or  in  the  neighborhood 
of  the  inflamed  patches  of  intertrigo  or  vaccinations,  it  spreads 
very  rapidly,  the  invaded  skin  becoming  infiltrated  and  swollen, 
and  at  the  points  of  most  intense  inflammation,  vesicles  may 
form,  and  these  points  may  be  followed  by  gangrene  with 
sloughing  of  large  areas,  but,  most  frequently,  they  terminate 
in  desquamation. 

Peritonitis  is  a  complication  quite  common  when  the  um- 
bilicus is  the  point  of  infection.  This  is  a  result  of  perforation 
of  the  abdominal  wall  by  the  gangrene  and  sloughing  induced 
by  the  severity  of  the  inflammation.  The  peritonitis  is  septic 
and  is  usually,  and  often  very  quickly,  fatal. 

Abscesses  may  occur  and  remain  in  an  inflamed  condition 
some  time  after  all  traces  of  inflammation  in  the  surrounding 
skin  have  disappeared.  If  situated  at  or  near  the  umbilicus, 
they  should  be  carefully  watched,  for  if  they  discharge  into  the 
peritoneal  cavity,  serious  results  will  follow. 

The  great  characteristic  symptom  of  erysipelas  is  its  tend- 
ency to  spread,  and,  unlike  other  diseases,  instead  of  one  attack 
immuning  against  another,  it  predisposes  the  skin  to  a  repeti- 
tion, and  these  facts  should  be  borne  carefully  in  mind,  and  the 
case  followed  some  time  after  all  symptoms  have  ceased,  for  it 
may  suddenly  be  relighted  in  a  more  malignant  form  and 
speedily  carry  off  the  already  exhausted  little  one. 

The  duration  of  the  disease  varies  with  the  intensity  of  the 
inflammation.  If  the  attack  be  light  and  uncompHcated,  the 
inflammation  usually  lasts  from  seven  to  ten  days,  but  some 
cases  may  be  prolonged  for  months.  In  fatal  cases,  however, 
death  occurs  on  an  average  of  twelve  days  after  the  appear- 
ance of  the  eruption,  and  in  most  of  them  death  occurs  from 
exhaustion. 

Diagnosis. — In  the  earliest  stages,  the  diagnosis  of  erysipelas 
is  an  impossibility ;  but  when  the  eruption  appears,  the  peculiar 
burning  pain,  the  characteristic  spreading,  etc.,  are  sufficient  to 
decide  the  diagnosis.  It  closely  resembles  erythema,  scarlet 
fever,  herpes,  zoster,  and  eczema ;  but  a  delay  of  a  few  hours 
or  even  a  day,  will  be  rewarded  by  enabling  a  positive  diagno- 
sis to  be  made. 

Prognosis. — Age  has  a  great  influence  in  the  prognosis  of  this 
disease.  In  very  young  infants  it  is  almost  always  fatal. 
When  occurring  in  babies  between  the  age  of  one  and  six 
months,  the  prognosis  should  be  guarded,  but  in  infants  over 
six  months,  and  the  attack  being  light,  it  may  generally  be  pro- 
nounced favorable.  However,  with  the  tendency  of  the  dis- 
ease to  recur  in  severer  forms,  and  in  already  over-taxed  pa- 
tients, the  prognosis  should,  in  all  cases,  be  guarded,  and  this  is 


788  THE  DISEASES  OF  CHILDREN. 

especially  true  when  those  who  are  naturally  weak  and  debili- 
tated are  affected. 

Treatment. — When  a  positive  diagnosis  has  been  made, 
prompt  measures  should  be  taken  at  once  to  prevent  its  spread, 
and  this  is  best  accomplished  by  either  bandaging  the  diseased 
portions,  or  removing  the  patient  to  a  room  where  it  can  be 
isolated  from  other  members  of  the  family.  In  all  cases,  no 
^  matter  how  simple,  strict  antiseptic  precautions  should  be  ob- 
served, both  to  prevent  auto-inoculation  and  otherwise  spread- 
ing the  disease. 

The  first  and  most  important  consideration  in  the  treatment 
is,  if  possible,  to  prevent  the  disease  from  spreading,  and  invad- 
ing other  portions  of  the  skin.  Various  methods  have  been 
advocated  for  the  purpose  of  circumscribing  the  inflammation, 
and  in  our  estimation  the  best  in  use,  at  the  present,  is  the  ap- 
plication of  the  tincture  of  iodine.  This  is  accomplished  by 
painting  a  circle  of  the  tincture,  an  inch  in  width,  around  the 
margins  of  the  inflamed  area. 

Irrigating  the  invaded  surfaces  with  antiseptic  washes,  or  the 
application  of  cold  compresses  of  calendula,  hamatnelis,  Hydras- 
tis, veratrum  viride,  or  of  weak  solutions  of  carbolic  acid,  mer- 
cury, etc.,  will  relieve  the  burning  pain  and  irritation ;  while 
rye  or  buckwheat  flour  dusted  over  the  diseased  patches  is  very 
cooling. 

If  the  child  is  weak  and  poorly  nourished,  some  one  of  the 
various  infant  foods,  that  after  repeated  trials  is  found  to  agree 
with  the  patient,  should  be  given.  If  the  bowels  are  irregular, 
they  should  be  attended  to  and  restored  to  their  normal  condi- 
tion. A  change  from  the  crowded  and  illy-ventilated  tenement 
houses  to  a  place  where  more  room,  sunlight  and  freedom  can 
be  obtained,  will  be  highly  beneficial.  If  the  disease  is  conse- 
quent upon  a  vaccination,  washing  with  a  two-per  cent,  solution 
of  carbolic  acid  and  dressing  with  Hydrastis,  with  the  internal 
administration  of  ars.,  bell.,  or  rhus  tox.,  whichever  is  best  indi- 
cated, will  be  followed  by  a  prompt  improvement.  When  ab- 
scesses threaten,  belladonna  will,  if  administered  in  time,  abort 
them  ;  otherwise,  they  should  be  encouraged  to  point,  by  heat, 
hepar  sulph.,  etc.,  and  then  opened  freely  with  a  bistuory.  For 
the  further  consideration  of  those  cases  that  require  surgical 
treatment,  the  reader  is  referred  to  the  standard  homeopathic 
works  on  surgery. 

Following  are  the  indications  for  the  remedies : 

Rhus  tox. — Great  restlessness  and  uneasiness ;  twitching  and 
jerking  of  the  muscles;  itching  over  the  whole  body;  stools, 
thin,  loose  and  dark  brown ;  pulse  very  rapid,  small  and  weak ; 
fever  with  chilliness ;  worse  at  night ;  vesicular  eruption. 


ERl'SIPELAS  (ST.  ANTHONY'S  FIRE).  789 

Apis. — Skin  swollen,  dry  and  mottled  ;  eruption  intense,  deep 
red,  and  accompanied  by  severe  stinging,  smarting  pains ; 
edematous  swelling  of  the  extremities  ;  stools  copious,  yellowish, 
and  occur  with  every  movement  of  the  body  ;  pulse  small,  rapid 
and  wiry ;  fever  without  thirst ;  tongue  furred. 

Arnica. — Face  and  eyes  sunken;  tongue  coated  white;  vom- 
iting of  food,  no  appetite,  great  thirst;  diarrhea,  stools  involun- 
tary, while  asleep,  undigested,  painful,  causing  patient  to  scream 
and  cry  out;  skin  red,  hot  and  painful,  edematous;  inflamma- 
tion of  skin  and  cellular  tissues,  very  painful  to  the  touch;  feet 
and  hands  cold,  but  body  very  hot. 

Arsenicum. — Great  restlessness;  violent  thirst;  vomiting; 
diarrhea,  stools  black  or  dark  green,  offensive  and  excoriating ; 
skin  cold  and  clammy,  with  gangrenous  aspect ;  exudation  of 
thin,  colorless,  acrid,  very  offensive  fluid  ;  typhoid  symptoms. 

Belladonna. — Convulsions;  eyes  widely  dilated  ;  violent  throb- 
bing of  the  carotids;  face  red  and  hot;  excessive  thirst,  vomit- 
ing, tongue  white  with  red  edges ;  stools  slimy,  with  offensive 
odor;  skin  red,  hot  and  shining;  eruption  smooth,  red  and  hot ; 
great  sensitiveness  of  entire  skin ;  pulse  full,  hard  and  rapid ; 
high  fever,  with  rigors. 

Cantharis. — Vesicular  eruption,  burning  and  stinging;  child 
cries,  screams  or  has  spasms  when  urinating ;  especially  useful 
after  the  too  free  use  of  arnica  externally. 

Lachesis. — Eruption  becomes  dark  blue,  black  or  mottled  ; 
gangrene;  ulcers  foul  and  angry  looking;  convulsions;  restless 
tossing  about,  with  meanings ;  thirst,  loss  of  appetite,  and  vom- 
iting ;  stools  sudden,  copious,  watery,  dark  and  very  offensive ; 
pulse  rapid  and  irregular. 


CHAPTER  VII. 

IMPETIGO   CONTAGIOSA  (PORRIGO  CONTAGIOSA). 

Definition. — Impetigo  contagiosa  is  an  acute,  contagious  in- 
flammation of  the  skin,  characterized  by  an  eruption  of  vesicles 
and  pustules,  and  accompanied  by  more  or  less  pruritis.  The 
vesicles  and  pustules  are  minute  points  appearing  in  clusters  or 
patches,  or  else  scattered  singly  over  the  surface.  When  occur- 
ring in  patches,  the  vesicles  and  pustules  are  closely  aggregated, 
and  when  broken  and  their  contents  discharged,  one  large 
crust  or  scab  is  formed,  which  varies  in  size  from  a  split  pea  to 
a  common  marble.  This  crust  is  yellowish  or  straw-colored, 
has  ridges  and  excavations  on  the  surface,  giving  it  an  umbili- 
cated  appearance,  and  looks  much  as  if  it  was  "  stuck  on  "  the 
skin. 

The  pus  from  the  pustules  is  highly  contagious  and  is  also 
auto-inoculable.  The  disease  is  spread  by  direct  contagion  and 
by  inoculation.  It  occurs  mostly  on  the  extremities,  but  is 
frequently  seen  on  other  portions  of  the  body.  When  occur- 
ring on  the  arms  the  pustules  are  smaller  and  rounded,  while 
those  on  the  lower  extremities  are  large  and  more  elliptical. 

Etiology. — Impetigo  contagiosa  is  chiefly  seen  among  the 
poor,  and  is  most  frequent  in  children  under  seven  years  of 
age.  It  is  due  to  the  inoculation  of  contagious  pus,  independ- 
ently of  its  source.  The  staphylococcus  awrens  is  the  most 
common  pathogenic  organism  of  this  affection.  Kissing,  as  be- 
tween children  and  parents,  may  carry  the  disease,  and  not  un- 
commonly several  cases  are  met  with  in  the  same  family. 

Symptomatology. — The  eruption  is  usually  preceded  by  a 
period  of  incubation  which  lasts  from  three  to  five  or  six  days. 
The  prodromal  symptoms  are  :  fever,  rapid,  small,  weak  pulse, 
loss  of  appetite,  diarrhea  or  constipation,  restlessness  and  sleep- 
lessness. After  the  third  day  the  eruption  generally  makes  its 
appearance,  consisting  of  numerous  fine  vesicles  situated  on  an 
inflamed  surface,  having  well-defined  margins.  When  first 
formed  the  vesicles  are  very  small  but  rapidly  enlarge  and  de- 
velop into  pustules.  They  are  slightly  raised  from  the  surface, 
and,  at  first,  are  filled  with  a  transparent  fluid,  which  in  a  few 
days  undergoes  suppuration. 

Soon  after  the  formation  of  the  pustules  they  break  and  their 
(790) 


IMPETIGO   CONTAGIOSA.  791 

contents  are  exuded  over  the  skin,  where  the  pus  slowly  forms 
thick,  yellow  scabs  or  crusts,  while  from  under  the  edges  of 
which  the  undried  pus  is  being  constantly  exuded. 

In  mild  cases  the  eruption  is  limited  in  extent,  but  in  severe 
cases,  and  especially  those  that  have  been  neglected,  the  entire 
extremity  or  extremities  may  be  involved  to  such  an  extent  as 
to  have  its  motion  and  utility  interfered  with.  When  the  ex- 
tent of  the  eruption  is  very  great,  there  are  generally  numerous 
cracks  or  fissures  in  the  crusts,  through  which  pus  is  constantly 
exuding,  and,  drying  on  the  old  scabs,  tends  to  increase  their 
thickness  to  an  enormous  extent.  It  often  happens  that  the 
nails  are  involved  when  the  eruption  has  extended  to  the  hands 
and  feet,  and,  when  so  involved,  they  usually  drop  off  and  are 
replaced  by  irregular  and  distorted  new  ones. 

With  the  appearance  of  the  vesicles,  a  sensation  of  heat, 
itching  and  smarting  is  felt,  which  varies  in  degree,  according 
to  the  mildness  or  severity  of  the  inflammation,  and  the  extent 
of  the  eruption.  The  duration  of  the  disease  varies  with  the 
subject,  lasting  in  some  two  weeks,  while  in  others  it  may  be 
prolonged,  by  auto-inoculation,  for  six  and  even  eight  months. 

After  their  formation,  the  crusts  generally  last  from  ten  to 
fourteen  days,  when  they  begin  to  exfoliate.  When  they  have 
loosened  and  fallen  off,  the  healing  process  is  unhindered  and 
proceeds  very  rapidly,  beginning  at  the  center  of  the  patch, 
and  gradually  working  towards  the  circumference.  In  some 
cases,  a  few,  small,  round,  elevated  spots,  situated  on  red 
patches,  are  seen  after  the  crusts  have  exfoliated,  but  they  soon 
disappear. 

Diagnosis. — Impetigo  contagiosa  is  most  liable  to  be  con- 
founded with  eczema,  scabies  and  varicella.  It  can  be  diag- 
nosed from  pustular  eczema  by  the  fact  that  the  eczematous 
eruption  is  more  confluent,  excites  intense  itching,  and  is  usu- 
ally associated  with  inflammation  and  infiltration  of  the  sur- 
rounding skin  ;  from  scabies  by  the  multiformity  of  lesions, 
the  intense  itching,  and  the  presence  of  acari,  in  the  latter,  and 
from  varicella  by  the  more  numerous  and  smaller  lesions  of 
chicken-pox,  and  their  distribution  over  almost  the  entire  body. 

Prognosis. — The  prognosis  is  generally  good.  Under  favor- 
able conditions  the  disease  will  terminate  spontaneously  in  two 
or  three  weeks.  It  may  be  prolonged  for  an  indefinite  period 
by  auto-inoculation,  but  is  never  dangerous  to  life. 

Treatment. — As  the  disease  is  so  highly  contagious,  means  to 
prevent  the  patient  from  scratching,  as  well  as  its  spreading, 
should  be  taken  at  once ;  and  this  is  best  accomplished  by 
gently  pressing  out  all  the  pus,  removing  the  crusts  with  warm 
carbolic  acid  solutions  and  applying  antiseptic  compresses. 


792  THE  DISEASES  OF  CHILDREN. 

After  the  removal  of  the  crusts,  the  raw  and  inflamed  sur- 
faces should  be  anointed  with  some  emollient  substance,  such 
as  olive-oil,  vaselin,  etc.  If  the  case  is  a  mild  one,  this  is  all 
the  treatment  that  will  be  necessary ;  but  in  severe  and  exten- 
sive cases  the  constitutional  symptoms  demand  attention. 

The  diet  should  be  carefully  looked  after,  and  the  patient,  if 
exhausted,  given  a  stimulating  and  highly-nourishing  diet.  Ab- 
solute cleanliness  is  indispensable,  as  is  also  plenty  of  good, 
pure,  fresh  air,  and  sunshine.  The  crusts  should  be  removed  as 
fast  as  formed  ;  and  if  there  is  much  pruritis,  dusting  the  sur- 
face with  equal  parts  of  starch  and  zinc  oxid  (the  greater  the 
extent  of  raw  surface,  the  more  starch  in  proportion  to  the  zinc 
should  be  used),  or  buckwheat  flour  will  be  very  effective.  Good 
results  often  follow  the  use  of  an  ointment  consisting  of  five 
per  cent,  of  resorcin  in  equal  parts  of  lanolin  and  vaselin.  In 
all  cases  the  discharges  should  be  removed  as  they  form. 

The  remedies  are  indicated  as  follows: 

Antimoniunt  criid. — Nausea,  vomiting;  no  appetite;  vesicles 
and  pustules  burn  and  sting;  eruption  mostly  on  face,  with 
brown,  scurfy  skin  between  the  patches. 

Antivionium  tart. — Excessive  restlessness ;  child  trembles  all 
over;  weakness  and  prostration;  eruption,  pustular,  thick,  and 
as  large  as  a  pea ;  eruption  leaves  painful,  bluish-red  marks  on 
the  face. 

Kali  bicJi. — Extreme  weakness ;  restless ;  pains  shoot  from 
one  patch  to  another;  nausea,  worse  in  morning;  pustular  erup- 
tion confined  to  forearms;  pustules  are  round  and  regular  in 
shape,  and  very  painful. 

Thuja. — Trembling  of  the  upper  extremities  ;  emaciation  and 
weakness ;  burning  stitches  in  various  parts ;  very  restless ; 
sleeplessness ;  eruption  mostly  on  lower  extremities ;  especially 
useful  when  the  disease  occurs  after  vaccination. 


CHAPTER  VIII. 

URTICARIA  (nettle-rash;    HIVES). 

Definition. — Urticaria  is  a  non-contagious,  inflammatory  con- 
dition of  the  skin,  characterized  by  an  eruption  consisting  of 
rapidly-formed  evanescent  wheals  of  a  whitish  or  reddish  color, 
accompanied  by  more  or  less  burning,  tingling  and  itching. 

The  lesions  vary  in  size  from  a  quarter  to  one  inch  in  diame- 
ter, occur  in  patches,  and  are  distributed  here  and  there  over 
the  cutaneous  surface.  The  number  of  wheals  varies  on  differ- 
ent parts  of  the  body,  being  most  numerous  on  the  arms;  and 
it  is  more,  their  size  and  not  their  number,  that  gives  size  and 
extent  to  the  patches. 

These  patches  are  surrounded  by  inflammatory  zones,  which 
have  well-defined  margins ;  and  the  inflammation  varies  in 
severity,  as  does  also  the  accompanying  pruritis  and  burning, 
according  to  the  extent  of  these  patches.  The  inflammation 
rarely  lasts  any  great  length  of  time,  generally  disappearing 
entirely  in  forty-eight  hours,  while  even  in  some  cases  the  pro- 
cess may  have  ceased  in  an  hour.  All  symptoms  usually  dis- 
appear in  five  or  ten  days. 

The  characteristics  of  the  wheals  presented  to  the  eye  are 
their  red,  white,  or  reddish-white  color,  their  varying  size  and 
irregular  shape,  their  occurring  in  patches,  and  the  well-marked 
border  of  inflammation  surrounding  the  patches ;  while  to  the 
touch,  they  are  hard  and  elevated  somewhat  above  the  surface 
of  the  skin,  and  their  surfaces  are  uneven.  To  the  eye  and 
touch,  they  are  almost  identical  with  the  wales  produced  by  a 
strong  blow  with  a  switch  on  the  skin.  The  common  name  of 
urticaria  is  nettle-rash,  while  it  is  sometimes  called  hives. 

Etiology. — The  causes  of  urticaria  may  be  divided  into  two 
classes,  viz.  :  predisposing  and  exciting. 

The  most  important  among  the  predisposing  causes,  is  a 
weak  and  delicate  skin,  that,  under  each  and  every  irritation, 
no  matter  how  slight,  is  ever  ready  to  take  on  some  form  of 
inflammation,  and  this  inflammation,  acting  in  conjunction  with 
proper  exciting  causes,  will  eventually  become  an  urticaria. 

This  susceptibility  of  the  skin  is  so  marked  in  some  children, 
that  even  the  taking  of  certain  substances  into  the  mouth  will 

(793) 


794  THE  DISEASES  OF  CHILDREN. 

cause  an  eruption  of  the  disease,  and  we  can  cite  a  case  of  a 
ten-year-old  boy,  who,  at  one  time,  had  no  sooner  taken  a  piece 
of  strong  cheese  into  his  mouth,  than  his  face  became  intensely 
red,  and  this  hyperemia  was  soon  followed  by  wheals,  which 
lasted  nearly  thirty-six  hours,  when  they  finally  disappeared. 

Anger,  fright,  or  some  other  intense  mental  excitement  has 
produced  it.  Seasons  also  have  considerable  influence  in  its 
causation,  as  the  majority  of  cases  occur  late  in  spring  or  early 
summer.  Excessive  clothing,  over-heated  rooms  and  too 
frequent  bathing  produce  a  tendency  to  its  appearance. 

Among  the  exciting  causes  that  are  to  be  mentioned  first,  are 
those  that  act  from  within.  The  most  important  of  these  are 
such  substances  that,  when  taken  into  the  irritable  stomach, 
nearly  always  found  accompanying  a  delicate  skin,  will  set  up 
reflex  action  and  irritate  the  skin  ;  such  substances  are  bella- 
donna, bromin,  cantharides,  iodin,  thus  tox.,  turpentine,  etc., 
and  in  addition  to  these  are  to  be  mentioned,  rich  pastry,  highly 
seasoned  foods,  strong  cheese,  lobsters,  oysters,  crabs,  canned 
and  salted  fish  and  meats,  pickles,  strawberries,  oily  nuts, 
olives  and  other  fatty  foods.  Worms  and  chronic  intestinal 
catarrh  are  common  causes  in  children. 

The  exciting  causes  acting  from  without  are  :  various  me- 
chanical injuries,  such  as  falls,  blows,  bruises,  whippings  ;  tight 
clothing  and  shoes  ;  irritations  of  orthopedic  instruments  ;  bites 
of  different  insects,  as  fleas,  mosquitoes,  bed-bugs,  spiders  ; 
stings  of  bees,  wasps,  hornets,  etc.;  and  some  drugs  applied  ex- 
ternally. The  most  common  external  cause  is  the  scratching 
induced  by  itching  from  whatever  source.  It  may  exist  in  con- 
nection with  other  skin  diseases,  and,  when  so  existent  is  the 
result  of  the  scratching ;  while  in  some  cases  it  may  be  so  ex- 
tensive as  to  entirely  mask  the  primary  disease,  making  diag- 
nosis of  that  affection  impossible. 

Symptomatology , — Urticaria,  when  occurring  in  the  adult,  is 
ushered  in  with  high  fever  and  more  or  less  febrile  disturbance  ; 
and  it  is  this  that  distinguishes  urticaria  occurring  in  the  adult 
from  that  which  occurs  in  infancy,  for  the  latter  has  no  fever 
and  only  slight  febrile  movement.  The  onset  of  the  eruption 
is  generally  preceded  by  symptoms  of  headache  or  congestion, 
great  restlessness,  weakness  and  languor,  vomiting,  variable 
condition  of  appetite  and  bowels,  tongue  thickly  coated  white, 
and  irritableness.  In  some  few  cases  there  are  no  prodromic 
symptoms,  the  eruption  being  ushered  in  with  a  most  intense 
pruritis  and  burning  which  causes  the  child  to  lose  all  self-con- 
trol and  give  way  to  paroxysms  of  scratching. 

The  eruption  consists  of  papules  or  small  tubercles  about  the 
size  of  a  split  pea,  and  of  a  red  or  white  color.     The  papules 


URTICARIA   {NETTLE-RASH;  HIVES).  795 

are  congregated  in  groups  or  clusters,  of  a  dozen  or  more, 
and  are  surrounded  by  bands  of  inflammation  with  well-defined 
margins  ;  and  these  patches  vary  in  size,  are  irregular  shaped, 
and  are  distributed  over  the  surface  either  singly  or  in  clusters. 
When  the  patches  occur  in  clusters,  the  papules  have  a  ten- 
dency to  coalesce  and  form  one  large  wheal,  which  is  generally 
of  a  greater  length  than  breadth. 

The  extent  of  the  eruption  varies  in  different  individuals,  but 
it  is  usually  limited  to  the  face,  arms,  back  and  thighs,  although 
it  may  involve  the  entire  skin.  In  the  center  of  the  papules 
are  white  spots,  which,  when  punctured,  exude  a  thin  colorless 
fluid.  The  eruption  rarely  lasts  over  forty-eight  hours,  and 
ends  in  a  slight  desquamation.  The  papules  that  are  first  formed 
do  not  last  long,  but  disappear  in  a  few  hours,  and  are  replaced 
by  others,  on  different  parts  of  the  body  or  on  the  same  site. 
So  fugitive  is  the  character  of  the  eruption,  that  by  the  time 
the  physician  responds  to  the  first  call,  it  may  have  entirely 
disappeared,  leaving  only  the  marks  produced  by  the  scratch- 
ing. The  wheals,  when  ruptured  by  scratching,  bleed  slightly, 
which,  drying,  form  little  scabs  on  their  apices. 

Diagnosis. — The  diagnosis  of  urticaria  is  exceedingly  easy,  as 
it  can  hardly  be  mistaken  for  any  other  disease.  The  evanes- 
cent character  of  the  eruption,  the  agonizing  pruritis,  and  the 
hard,  elevated,  white  or  red  wheals  are  met  with  in  no  other 
skin  disease.  Dermatitis  contusiformis,  however,  has  many  of 
the  features  of  urticaria,  but  it  can  be  differentiated  by  the 
regular  course,  intense  hyperemia,  regularity  of  shape  of  no- 
dules, and  the  entire  absence  of  pruritis  of  the  dermatitis. 

Prognosis. — There  are  no  cases  on  record,  where  death  has 
been  the  direct  result  of  urticaria.  It  is  an  exceedingly  mild 
disease,  and  the  prognosis  is  always  favorable,  although  among 
the  poorer  classes,  where  proper  hygienic  measures  cannot  be 
enforced,  the  disease  may  be  prolonged  indefinitely.  It  has  no 
dangerous  symptoms,  and  when  such  are  present,  are  always 
dependent  upon  the  gastric  disorder  or  w-hatever  produced  the 
disease.  The  papular  form  in  children  often  proves  very  ob- 
stinate. 

Treatment. — The  first  and  most  important  point  in  the  treat- 
ment, is  the  removal,  if  possible,  of  the  cause  of  the  eruption. 
If  it  be  the  result  of  an  over-loaded  stomach,  the  stomach 
should  be  emptied  by  a  gentle  emetic.  If  due  to  diarrhea  or 
constipation,  the  bowels  should  be  carefully  attended  to  and 
returned  to  their  normal  condition.  All  errors  of  diet,  clothing, 
etc.,  are  to  be  corrected.  If,  for  some  reason,  the  child  is  in  a 
constant  state  of  nervous  tension,  steps  to  the  removal  of  the 
nervousness  should  at  once  be  taken,  and  the  child  kept  as 


796  THE  DISEASES  OF  CHILDREN. 

quiet  as  possible.  When  occurring  in  little  boys  with  phymo- 
sis,  they  should  be  circumcised  immediately,  the  sooner  the 
better.  In  little  girls,  the  hood  of  the  clitoris,  if  adherent, 
should  be  loosened,  and  all  smegma  thoroughly  removed.  If 
due  to  a  filthy  condition,  whereby  body  lice  are  contracted,  ab- 
solute cleanliness  should  be  insisted  upon,  which  will,  in  most 
cases,  be  destructive  to  the  lice. 

After  all  causes  have  been  removed,  the  attention  should  be 
directed  to  the  alleviation  of  the  pruritis,  and  this  is  best  ac- 
complished by  irrigation  with  some  alkaline  or  antiseptic  solu- 
tion. If  the  eruption  be  simply  local  or  of  small  extent,  two 
per  cent,  carbolic  acid  or  bi-chlorid  mercury ,  one  to  two  thou- 
sand may  be  used.  If  the  skin  be  unbroken,  the  patches  may 
be  washed  with  warm  salt  water.  Buckwheat  or  rye  flour,  or 
equal  parts  of  oxid  of  zinc  and  starch,  dusted  over  the  patches, 
has  a  decided  anti-pruritic  action. 

In  all  cases,  strict  cleanliness  should  be  observed,  and  the 
diet  carefully  watched,  so  that  if  the  eruption  is  due  to  some 
improper  food,  that  article  can  be  detected  and  at  once  removed 
from  the  child's  regimen.  If  the  patient  be  weak  and  debili- 
tated, a  good  stimulating  as  well  as  nourishing  diet  should  be 
ordered  and  given  in  such  quantities  as  best  suits  the  demands 
of  the  system.  Outdoor  exercise  and  plenty  of  fresh  air  and 
sunshine  are  very  beneficial. 

The  remedies  are  indicated  as  follows : 

Apismel. — Tired,  weak, languid,  with  trembling  of  the  limbs; 
the  eruption  stings  and  burns  like  stings  of  bees,  wasps,  hornets 
and  other  insects;  eruption  intensely  red,  and  pruritis  worse  at 
night ;  eruption  spread  over  nearly  entire  body. 

Arsenicum  alb. — Intense  thirst,  great  restlessness  and  sleep- 
lessness; eruption  of  a  deep-red  color,  and  confined  to  face  and 
arms ;  the  eruption  burns,  is  exceedingly  painful,  and  is  aggra- 
vated by  scratching;  wheals  greatly  enlarged  by  scratching. 

Belladonna. — Symptoms  of  congestion  of  head ;  tongue  red,, 
with  white  streak  in  center;  skin  hypersensitive;  eruption  of  a 
bright-red  color,  surrounded  by  deep-red  border ;  burning  and 
itching  comes  and  goes  periodically  and  suddenly. 

Calcarea  carb. — Child  weak,  muscles  flabby,  and  skin  very 
unhealthy;  eruption  tends  to  become  chronic;  the  eruption  is 
hard,  very  light  colored,  elevated  and  situated  on  white  surface^ 
and  disappears  on  going  out  in  open  air. 

Cina. — Digging  and  scratching  at  the  nose ;  twitching  and 
jerking  of  the  muscles;  eruption  first  appears  about  the  nostrils 
and  from  there  spreads  over  face  and  back  ;  eruption  from  worm 
troubles. 

Conium. — Child  takes  cold  very  easily ;  is  weak  and  easily 


URTICARIA   {NETTLE-RASH;  HIVES).  797 

exhausted;  eruption  mostly  on  back  and  thighs;  pruritis  and 
stinging  like  bites  of  insects;  aggravation  at  night  and  from 
scratching. 

Graphites. — In  weak,  thin,  poorly-nourished  children ;  the 
eruption  is  spread  over  entire  body ;  itching  and  burning  ag- 
gravated by  scratching  and  at  night ;  sour-smelling  perspira- 
tion when  warm  in  bed,  or  skin  is  dry  with  tendency  to  fissure. 

Podophyllum. — Tongue  heavily  coated  white  ;  diarrhea,  with 
dark-green,  watery  stools,  passed  with  much  flatus;  is  very 
sleepy  during  the  morning,  but  wakeful  at  night;  eruption  con- 
fined to  back  and  arms ;  intense  pruritis  unrelieved  by  scratch- 
ing ;  eruption  aggravated  by  scratching. 

Pulsatilla. — Eruption  caused  by  eating  pastry,  fatty  foods, 
highly  seasoned  articles,  etc. ;  itching  very  evanescent,  rapidly 
shifting  from  one  spot  to  another;  eruption  is  red,  elevated 
and  very  hot ;  scratching  slightly  relieves  pruritis,  which  is 
aggravated  from  warmth  of  bed. 

Ruta. — Nausea  and  vomiting  brought  on  by  drinking  milk ; 
constipation  with  rumbling  in  bowels ;  eruption  brought  on  by 
eating  meat ;  intolerable  pruritis  all  over  the  body,  aggravated 
by  cold  air,  but  relieved  by  scratching. 

Sulphur. — Weakness  and  languor  ;  aversion  to  washing ;  of- 
fensive smell  from  child  who  is  exceedingly  dirty;  eruption 
frequently  due  to  body  lice ;  eruption  on  whole  body ;  burning 
and  itching  relieved  by  scratching,  but  worse  from  warmth  of 
bed  ;  especially  useful  in  chronic  cases. 

Zinc  met. — Child  dull,  stupid  and  greatly  emaciated ;  muscles 
twitch  and  jerk;  itching  seems  to  be  between  skin  and  flesh; 
the  eruption  appears  immediately  after  eating  or  taking  a  bath. 


CHAPTER  IX. 

TRICHOPHYTOSIS     (RINGWORM). 

Definition. — Trichophytosis  is  a  contagious  affection  of  the 
skin  due  to  the  development  of  the  trichophyton  fungus  in  the 
hairs,  hair-follicles  and  epidermis. 

As  observed  in  children,  it  may  be  most  conveniently  de- 
scribed under  the  regional  forms  of  trichophytosis  corporis  or 
ringworm  of  the  general  surface,  and  trichophytosis  capitis  or 
ringworm  of  the  scalp. 

Etiology. — Trichophytosis  is  caused  by  the  trichophyton,  a 
vegetable  parasite  which  consists  of  spores  and  mycelia,  but 
especially  of  spores.  It  is  highly  contagious,  and  is  readily 
communicable,  either  directly  from  one  person  to  another,  or 
through  the  medium  of  wearing  apparel,  or  of  the  various  arti- 
cles of  the  toilet. 

It  is  met  with  in  the  horse,  dog,  cat,  cow,  rabbit,  and  other 
domestic  animals,  and  may  be  transmitted  by  them  to  man. 

Trichophytosis  capitis  is  most  common  in  fair-haired,  poorly- 
nourished  children.  It  is  seldom  met  with  in  infancy,  or  after 
puberty. 

Trichophytosis  corporis  may  occur  at  any  age,  but  is  uncom- 
mon after  fifty.  It  is  of  more  frequent  occurrence  in  children 
than  in  adults. 

Symptomatology. — Trichophytosis  corporis  is  more  common 
upon  the  fact,  neck,  arms  and  exposed  parts,  but  may  appear 
upon  any  part  of  the  body.  It  begins  as  a  small,  light-red, 
slightly  scaly  spot,  presenting  a  circular,  sharply-defined, 
slightly  elevated  border,  which  may  be  either  papular  or  ve- 
sicular. As  the  spot  increases  at  the  periphery,  it  frequently 
displays  a  tendency  to  clear  up  in  the  center,  and  the  lesion  as- 
sumes a  ring-shape  appearance.  Not  infrequently  pale-red,  cir- 
cular, well-defined,  scaly  patches,  which  extend  centrifugally, 
but  do  not  clear  up  in  the  center,  are  observed  to  take  the 
place  of,  or  occur  in  connection  with,  the  more  typical  ring  for- 
mations. The  patches  or  rings  may  be  one  or  several,  ordina- 
rily but  two  or  three  are  present.  They  may  attain  the  size  of 
a  half  inch  or  larger,  and  may  remain  separate  or  coalesce  and 
form  gyrate  or  crescentic  figures.  They  give  rise  to  bui  little 
(798) 


TRICHOPH7-TOSIS  {RINGWORM).  799 

physical  discomfort,  other  than  slight  itching,  and  may  con- 
tinue for  days,  weeks,  or  months,  if  allowed  to  remain  untreated. 

Ringworm  of  the  body  may  coexist  with  ringworm  of  the 
scalp. 

Trichophytosis  capitis  is  almost  exclusively  confined  to  chil- 
dren. Not  infrequently  it  prevails  in  schools  and  public  insti- 
tutions as  an  epidemic.  It  begins  around  a  hair,  as  a  red  point 
which  increases  peripherally,  and  soon  becomes  a  well-defined 
pale  or  grayish-red  patch,  covered  with  fine,  white  scales.  Us- 
ually attention  is  first  directed  to  the  affection  by  the  presence 
of  one  or  more,  generally  circular,  variously-sized  patches  with 
sharply-defined  borders,  covered  with  ashen-gray  scales  and 
stumps  of  dull,  lusterless  hair.  It  may  remain  limited  to  one 
or  more  spots,  or  invade  the  entire  scalp.  Sometimes  it  be- 
comes disseminated,  and  may  then  readily  escape  detection,  as 
the  scaliness  is  slight  and  the  stumps  are  few.  Occasionally  it 
shows  a  tendency  to  spread  beyond  the  line  of  the  hair  and 
down  upon  the  adjacent  uncovered  skin.  After  it  has  existed 
for  some  time  the  patches  may  assume  a  bluish  or  slate-colored 
appearance.  Itching  in  various  grades  of  severity,  though 
usually  mild,  is  commonly  present. 

Early  in  the  disease,  the  hairs  undergo  alterations,  and  become 
bent,  twisted  and  brittle.  The  broken  hairs  are  of  a  lighter 
color  than  the  neighboring  healthy  hair,  and  their  extremities 
are  ragged  and  often  brush-like.  In  very  fair,  fine-haired  chil- 
dren, the  hairs,  instead  of  sticking  up,  are  apt  to  lie  close  to  the 
skin,  and  appear  thickened  and  matted.  On  attempting  to  ex- 
tract the  short  hair-stumps  with  the  epilation  forceps,  it  will  be 
found  that  many  of  them  break  off,  leaving  the  root  in  the  fol- 
licle. Under  the  microscope,  with  the  power  of  three  or  four 
hundred  diameters,  an  extracted  hair-stump,  after  being  soaked 
in  a  few  drops  of  liquor,  and  then  potassae,  will  be  seen  to  be 
stuffed  with  the  minute  spores  of  the  trichophyton.  The  ash- 
en-gray scales  of  the  affected  scalp  are  found  to  exhibit  traces 
of  the  fungus,  though  to  a  less  extent  than  the  invaded  hairs. 
The  hair-shaft  is  often  longitudinally  split,  the  growth  of  the 
parasite  having  forced  the  elements  apart. 

Trichophytosis  capitis  may  be  either  acute  or  chronic,  and 
when  left  to  itself  it  may  persist  indefinitely. 

Pathology. — The  seat  of  the  trichophyton  fungus  is  in  the 
hair,  hair-follicles  and  epidermis,  where,  by  its  development,  it 
produces  the  various  clinical  appearances  of  the  disease. 

Diagnosis. — The  diagnosis  of  trichophytosis,  in  typical  cases, 
is  usually  easy.  The  peculiar  clinical  features  in  ringworm  of 
the  body,  especially  the  rapid  development  of  the  circles,  with 
a  tendency  to  clear  up  in  the  center,  and  the  presence  of  bent, 


800  THE  DISEASES  OF  CHILDREN. 

broken  and  twisted  hair-stumps  in  ringworm  of  the  scalp  are 
sufficiently  characteristic.  In  all  forms,  the  discovery  of  the 
trichophyton  fungus  in  the  scales  and  hairs  will  establish  the 
diagnosis  with  certainty. 

The  only  diseases  with  which  it  is  liable  to  be  confounded, 
are  seborrhea,  psoriasis  and  alopecia  areata. 

In  seborrhea  the  scaliness  is  diffuse,  and  the  thinning  of  the 
hair,  when  present,  is  general,  and  there  are  never  any  broken- 
off  hair-stumps. 

In  psoriasis  the  scales  are  more  abundant  than  in  trichophy- 
tosis, the  patches  are  more  symmetrically  distributed,  and  there 
are  never  any  short  stubbly  hairs. 

In  alopecia  areata  the  hairs  fall  out  entire,  leaving  patches  or 
bands  of  perfectly  bald,  smooth,  white  skin.  Where  there  is 
doubt,  recourse  must  be  had  to  the  microscope. 

Prognosis. — While  the  prognosis  in  all  forms  of  ringworm  is 
usually  favorable,  it  should  be  guarded  as  to  the  length  of  time 
required  to  affect  a  cure.  Trichophytosis  corporis  is  generally 
curable  in  one  or  two  weeks,  while  trichophytosis  capitis  is  rarely 
cured  within  four  or  six  months. 

Treatment. — The  treatment  of  trichophytosis,  when  the  dis- 
ease is  superficial,  as  in  ringworm  of  the  body,  is  easy  and 
promptly  curative  ;  while  that  of  ringworm  of  the  scalp  is  tedi- 
ous, owing  to  the  mechanical  difficulty  of  carrying  the  parasiti- 
cide deeply  enough  to  reach  the  fungus  in  the  hair-follicles. 

In  trichophytosis  corporis  the  scales  should  be  removed 
with  soap  and  hot  water,  and  the  lesions  well  rubbed  twice  a 
day  with  almost  any  antiparasitic  ointment,  preferably  one 
composed  of  sulphur  one  drachm,  carbolic  acid  twenty  minims, 
lanolin  five  drachms,  and  olive  oil  three  drachms  ;  or  an  oint- 
ment of  ammoniated  mercury,  fifteen  to  forty  grains  to  the 
ounce  of  lanolin  and  olive  oil  or  lard.  A  few  applications  of 
tincture  of  iodin  or  of  dilute  acetic  acid  often  prove  effective. 
Ordinary  writing-ink,  and  a  copper  cent  that  has  lain  in  vine- 
gar, are  valued  remedies  among  the  laity. 

In  trichophytosis  capitis  the  hair  should  be  cut  short  for  at 
least  a  half  inch  all  around  the  affected  spot  or  spots,  the  scales 
cleaned  from  the  scalp,  and  the  diseased  hairs  extracted  by 
means  of  a  properly  constructed  epilation  forceps.  The  para- 
siticide, preferably  a  bi-chlorid  of  mercury  solution,  one  to 
three  grains  to  the  ounce,  or  an  ointment  of  the  oleate  of  cop- 
per, a  half  drachm  to  one  drachm  to  the  ounce  should  be  im- 
mediately applied,  and  well  rubbed  in  twice  a  day. 

Electric  cataphoresis  may  be  employed  with  good  results, 
using  a  one  per  cent,  bi-chlorid  of  mercury  solution  in  connec- 
tion with  the  anode. 


TRICHOPHYTOSIS  {RINGWORM).  801 

Epilation  should  be  repeated  weekly,  and  local  treatment 
continued  as  long  as  necessary.  The  strictest  attention  should 
be  given  to  cleanliness,  and  all  bonnets,  hats,  caps  or  other 
head-gear,  as  also  hair-brushes,  combs,  etc.,  that  have  been  pre- 
viously used,  should  be  destroyed.  In  schools  and  public  insti- 
tutions the  separation  of  affected  individuals  and  of  their  cloth- 
ing, should  be  rigidly  enforced,  in  order  to  prevent  the  further 
spread  of  the  disease. 

The  most  important  internal  remedies  are  sepia  and  /^//«- 
rium.     Others  occasionally  of  service  are  :  arsenicutn^  alb.,  caU 
carea  curb.,  and  sulphur. 
D.  C— 51 


CHAPTER  X. 

SCABIES   (itch). 

Definition. — Scabies  is  a  contagious  disease  of  the  skin  caused 
by  an  animal  parasite  called  the  acarus  scabiei.  The  disease  is 
characterized  by  the  formation  of  vesicles  and  pustules  situated 
on  inflamed  bases,  and  also  by  the  intense  nightly  aggravation 
of  the  itching. 

Scabies,  though  common  in  Great  Britain  and  on  the  Conti- 
nent, is  a  comparatively  rare  disease  in  this  country,  constitut- 
ing, in  my  experience,  only  about  two  per  cent,  in  private 
practice. 

As  soon  as  the  acari  have  alighted  on  the  skin,  they  immedi- 
ately proceed  to  burrow,  the  male  going  only  deep  enough  to 
secrete  himself  under  the  scales  of  the  superficial  stratum,  while 
the  female  constructs  a  long,  tortuous  canal  or  cuniculus  in 
which  she  deposits  her  eggs  as  she  advances.  After  she  has 
finished  laying  her  eggs,  she  remains  at  the  end  of  her  cunicu- 
lus, where,  in  a  few  weeks,  she  dies,  unless  removed  or  killed 
by  treatment  sooner. 

On  the  tenth  day,  the  ova  are  hatched,  and  as  soon  as  the 
young  acari  mature,  they  seek  the  surface,  where  the  young 
females  become  impregnated,  and  they  in  turn  begin  burrowing 
and  laying  eggs  as  they  advance.  These  canals  or  cuniculi  are 
in  appearance  much  like  a  needle  scratch,  and  have  at  one  end 
a  fine,  white,  glistening  point,  which  can  be  easily  removed 
with  a  fine  needle,  and  these  points,  placed  under  a  microscope, 
prove  to  be  the  female  acari.  The  male  acarus  never  burrows, 
and  is  very  rarely  detected.  The  female  acari,  by  burrowing, 
produce  the  itching;  and  being  more  active  at  night  than  dur- 
ing the  day,  give  rise  to  the  nightly  aggravation.  The  inflam- 
mation, vesicles  and  pustules  are  caused  by  the  scratching. 

Etiology. — Scabies  is  the  most  contagious  of  all  the  skin  dis- 
eases. It  requires  no  particular  susceptibility  of  the  cuticle  to 
its  influence,  but  may  be  transmitted  by  direct  contact  with 
the  disease,  by  sleeping  in  bed  with  an  infected  person,  or  by 
wearing  the  clothing  previously  worn  by  a  diseased  subject. 

It  is  mainly  a  filth  disease,  and  is  much  more  common  among 
the  poor  and  those  who  are  careless  of  their  personal  cleanli- 
ness, than  among  the  better  classes.  In  the  poorer  classes, 
(802) 


SCABIES  i^ITCH).  808 

where  cleanliness  is  almost  entirely  neglected,  and  the  people 
live  in  crowded  and  poorly-ventilated  houses,  the  means  of 
communication  are  particularly  numerous,  and  it  is  among  these 
classes  that  the  majority  of  cases  of  scabies  occur. 

The  principal  etiological  factor  of  the  disease  is  the  acarus 
scabiei.  This  parasite,  or  evidences  of  its  being  present,  is 
found  in  every  case  of  scabies,  and  its  cuniculus  is  one  of  the 
diagnostic  symptoms  of  the  disease.  The  acarus  is  shaped 
much  like  a  turtle.  The  neck  is  long  and  can  be  elongated  or 
retracted;  and  the  head  is  provided  with  two  jaws.  A  full- 
grown  acarus  has  four  pairs  of  legs,  two  anterior  and  two  pos- 
terior ;  the  anterior  pairs  being  articulated  and  armed  with 
suckers,  while  the  posterior  pairs  are  covered  with  hairs.  On 
the  back  are  numerous  fine  spines  or  projections  pointing  up- 
ward and  posteriorly,  which  effectually  prevent  the  creature's 
retrogressing.     The  young  acari  have  but  six  legs. 

Symptomatology. — The  period  of  incubation  of  this  disease 
varies  according  to  the  degree  of  healthfulness  of  the  child, 
and  lasts  from  two  to  five  days.  In  healthy  children  the  erup- 
tion usually  appears  about  two  days  after  the  exposure,  while 
in  sickly  and  poorly-nourished  infants  it  does  not  appear  for 
four  or  even  five  days. 

The  first  noticeable  symptom  is  a  more  or  less  redness  of  the 
skin  of  the  part  exposed.  This  redness  is  soon  followed  by  a 
true  inflammation  and  with  the  formation  of  minute  pearly  ves- 
icles, and  accompanied  by  intolerable  itching.  Frequent  scratch- 
ings  rupture  these  vesicles  and  their  contents  are  exuded  over 
the  skin.  This  fluid  is  highly  contagious,  and  being  carried  to 
the  surrounding  surface,  sets  up  a  new  inflammation  with  ves- 
icles, and  in  this  way  is  the  disease  extensively  and  rapidly 
spread. 

The  vesicles  when  first  appearing  are  minute  points  filled 
with  a  colorless  fluid,  which  soon  becomes  opaque,  and  in  scrof- 
ulous subjects,  rapidly  changes  to  pus  and  forms  pustules.  The 
number  of  vesicles  varies ;  in  some  cases  they  are  very  numerous, 
while  in  others  they  are  scarce.  They  are  generally  isolated, 
irregular  in  size,  are  somewhat  elevated  above  the  surrounding 
skin,  and  are  sometimes  intermixed  with  the  eruptions  of  inter- 
trigo, psoriasis  and  lichen.  They  frequently  are  ruptured  spon- 
taneously, but  more  often  by  scratching  ;  and  from  their  exuded 
contents  small  thin  scabs  are  formed.  Sometimes  the  scratch- 
ing is  so  severe  as  to  cause  bleeding,  and  when  such  is  the  case, 
the  scabs  are  thick  and  black.  There  is  a  particular  preference 
shown  by  the  scari  for  the  thin  portions  of  the  skin,  such  as  is 
between  the  fingers  and  toes,  covering  the  ano-genital  region, 
on  the  inner  aspect  of  the  thighs  and  arms,  and  on  the  backs 


804  THE  DISEASES  OF  CHILDREN. 

of  the  hands  and  feet.  As  it  is  communicated  by  contact  from 
one  child  or  person  to  another,  the  first  symptoms  will  be  no- 
ticed on  the  part  so  exposed  ;  and  this  site  varies  with  the  age 
of  the  children.  In  infants,  the  thighs  and  buttocks,  from  the 
frequency  with  which  they  are  handled,  are  usually  the  starting 
point ;  while  in  older  children  and  those  old  enough  to  wear 
long  night  clothes,  the  wrists,  fingers  and  ankles  suffer  the  on- 
set, and  from  these  sites  it  is  quickly  spread  by  scratching  and 
friction. 

The  intense  nightly  itching  sets  up  various  irritations  in  the 
affected  child,  principal  among  which  are  sleeplessness  and  di- 
gestive disturbances,  with  their  long  train  of  sympathetic 
symptoms ;  but  these  generally  disappear  very  quickly  when 
the  cause  has  been  removed.  As  before  stated,  scabies  is  very 
amenable  to  treatment,  but  from  improper  food,  lack  of  cleanli- 
ness, careless  treatment,  etc.,  the  disease  may  continue  indefi- 
nitely, setting  up  symptoms  which  eventually  become  chronic, 
leaving  the  system  in  a  condition  susceptible  to  the  attacks  of 
various  diseases,  and  which,  from  the  weakened  condition,  may 
rapidly  carry  the  little  one  to  the  grave. 

Diagnosis. — As  the  acarus  is  the  cause  of  this  disease,  then, 
naturally,  the  presence  of  this  parasite,  its  burrow,  or  other  evi- 
dences of  its  presence,  will  be  the  diagnostic  symptoms,  but  fre- 
quently, from  the  scratch  marks,  these  characteristics  cannot  be 
detected,  and  from  its  resemblance  to  various  other  skin  dis- 
eases, the  diagnosis  is  exceedingly  difficult. 

According  to  Kippax,  the  following  symptoms,  where  they 
can  be  found,  will  be  sufficient  to  differentiate  scabies  from  the 
other  eruptions  which  it  may  resemble : 

"  I.  The  presence  of  cuniculi  with  their  contained  acari. 

"2.  The  seat  of  the  eruption,  which  is  mostly  in  the  interdig- 
its  and  wrists,  and  in  the  flexures  of  the  body,  the  buttocks 
and  the  dorsal  surface  of  the  penis.  Scabies  seldom  appears 
above  the  nipple  line. 

"3.  The  multiformity  of  the  eruption. 

"4.  The  itching,  which,  though  continuing  during  the  day, 
is  characteristically  worse  at  night. 

"  5.  The  evidence  of  contagion  in  the  household,  other  mem- 
bers of  the  family  being  affected. 

"6.  The  rapid  disappearance  of  the  symptoms  under  parasiti- 
cidal  treatment." 

Prognosis. — Scabies,  in  itself,  is  a  mild  disease  and  has  no 
severe  constitutional  symptoms,  and  through  an  improper  di- 
agnosis it  may  be  prolonged  for  years,  but  when  correctly  diag- 
nosed the  prognosis  is  always  good,  as  it  yields  so  readily  to 
treatment. 


SCABIES  {ITCH).  805 

Treatment. — As  the  disease  is  of  parasitical  origin,  the  best 
treatment  would  be  that  which  would  destroy  these  parasites 
the  quickest,  and  do  the  least  harm  to  the  patient.  According 
to  M.  Gras,  who  has  experimented  for  years  with  the  acarus, 
it  is  killed 

When  immersed  in  vinegar  in  20  minutes. 
When  immersed  in  alcohol  in  20  minutes. 
When  immersed  in  turpentine  in  9  minutes. 
When  immersed  in  potass,  iod.  in  4-6  minutes. 

It  will  be  seen  from  the  above  table  that  turpentine  and  pot- 
ash are  particularly  destructive  to  this  pest  and  hence  their 
use  in  the  treatment  will  be  followed  by  prompt  results.  Be- 
sides these  two  remedies,  sulphur  also  stands  high  as  an  anti- 
parasiticide.  These  substances  are  to  be  used  in  the  form  of 
an  unguent,  care  being  taken  to  vary  their  strength  according 
to  the  extent  of  surface  over  which  they  are  to  be  spread. 

Before  applying,  the  child  is  to  have  a  warm  bath,  and  a 
thorough  scrubbing  with  soap  in  order  to  remove  all  possible 
dirt,  scabs,  scales  and  other  debris,  and  soften  the  skin.  Then 
apply  the  ointment,  wrap  the  child  up  well  and  put  it  to  bed. 
In  the  morning  another  bath  should  be  given,  and  at  night 
again  a  third  bath  and  another  rubbing  with  the  ointment. 
Two  or  three  applications  are  usually  sufficient  to  effect  a  cure. 
They  should  be  kept  up  until  all  itching  has  ceased.  All  the 
clothing  and  bedding  used  by  the  patient  should  be  carefully 
sterilized  or  fumigated  before  they  are  used  again. 

The  sulphur  may  be  used  as  strong  as  100  grains  to  the 
ounce  of  vaselin  for  children  over  five  years,  while  younger 
children  should  have  from  60  grains  down.  The  turpentine  15 
to  20  drops,  decreasing  the  strength  for  youth  and  extent  of 
surface,  while  the  potash  is  to  vary  from  5  to  20  grains  per 
ounce.  A  solution  of  i  per  cent,  carbolic  acid  or  bi-chlorid  of 
mercury  1-5000,  is  very  effective,  being  highly  destructive  to 
the  acarus  and  harmless  to  the  patient.  The  bi-chlorid  should 
not  be  used  too  freely  in  the  very  young.  In  small  children 
balsam  of  Peru  will  prove  an  efficient  application. 


INDEX. 


♦'A.  B.  C."  Cereal  food,  58. 

Abscess  of  ear,  123. 

Abscess  in  nursing,  mammary,  36. 

Abscess,  retro-pharyngeal,  532. 

Accidents  of  birth,  36. 

Adenitis,  642 ;  definition,  642 ;  eti- 
ology, 642  ;  treatment,  645. 

Albuminuria,  426. 

Alcohol,  use  of,  in  infants,  21. 

American -Swiss  food,  59. 

Amygdalitis.     See  Tonsilitis. 

Anatomical,  peculiarities  of  infants, 
20. 

Anemia  in  nursing,  36. 

Angina,  cause  of  ear  trouble,  122. 

Apex  beating,  16. 

Aphthae,  157. 

Appearance  of  nurse,  42. 

Arteries  in  infancy,  5. 

Artificial  food,  40. 

Asphyxia  at  birth,  27 ;  causes,  27 ; 
diagnosis,  27 ;  treatment,  27 ;  Dr. 
Parker  on,  28. 

Asthenia  at  birth,  26 ;  treatment,  26. 

Asthma,  577. 

Astigmatism,  106. 

Atelectasis,  583. 

Ataxy,  hereditary,  710. 

Ataxy,  locomotor,  acquired,  ^12. 

Atropine,  use  of,  in  infancy,  21. 

Attitude  in  disease,  12. 

Auditory  canal  at  birth,  116. 

Auditory  nerve,  destruction  of,  effects 
of  on  internal  ear,  139. 

Aural  remedies,  141. 

Auscultation,  15 ;  mode  of,  in  chil- 
dren, 16. 

B 

Baby,  dressing  of,  67, 

Bath,  daily,  69;  directions  for,  70; 
time  for,  71  ;  hot  bath,  23;  in  col- 
lapse, 23 ;  diarrhea,  23 ;  in  shock, 
23;  in  vomiting,  23;  Bright's  dis- 
ease, 23;  constipation,  23. 


Bathing,  the  cause,  ear  disease,  122. 

Beck,  Dr.  J.  B.,  on  narcotics,  20. 

Bed  for  baby,  description  of,  73. 

Bernard,  Dr.  Claude,  on  pathology 
of  dyspepsia,  177. 

Billiard,  Dr.,  on  gastritis,  166. 

Births,  accidents  and  diseases  imme- 
diately following,  26. 

Blair's  wheat  food,  58. 

Blepharitis,  94. 

Blood,  in  infanc}',  5. 

Blows,  effects  of  on  internal  ear,  147; 
on  eyes,  iii. 

Bones,  in  infancy,  3. 

Boxing  the  ears,  121. 

Brain,  diseases  in  ear  trouble,  122; 
in  infancy,  4;  development  of,  4; 
tumors  of,  147. 

Breasts  of  wet-nurse,  42. 

Bright's  disease,  439;  bath  in,  23. 

Bronchitis,  565  ;  capillary,  568. 

Broncho-pneumonia,  552. 

Burns  of  eye,  iii. 


Calculi  in  urinary  passages,  462. 

Cancer,  in  nursing,  36;  of  bladder, 
456;  of  kidneys,  456;  treatment, 
medical  and  surgical,  458. 

Cancrum  oris,  161. 

Carbonic  acid,  in  infancy,  6. 

Catarrh,  intestinal,  183;  gastric,  166; 
of  throat  in  ear  disease,  122;  mid- 
dle ear,  123. 

Cephalhematoma,  28 ;  effects  on  ear, 
146. 

Cerebro-spinal  fever,  604;  Dr.  J. 
Lew^is  Smith  on,  604;  in  relation  to 
eye  diseases,  109. 

Chalazion,  99. 

Charcot's  sclerosis,  677. 

Charles  on  24  hrs.  urine,  420. 

Cheadle,  Dr.,  formula  for  humanized 
milk,  49. 

Cheyne-Stokes  breathing,  6. 

Chicken-pox  (see  Varicella),  322. 

(807) 


808 


INDEX. 


Childhood,  period  of,  i. 

Children,  auscultation  of,  15;  height 
of,  8;  examination  of  sick,  13;  pal- 
pation of,  16;  percussion  of,  17 ; 
weight  of,  table  of,  8. 

Cholera  infantum,  193;  diagnosis,  195; 
mortality  in,  184;  nature  of,  193; 
symptoms,  193 ;  treatment  of,  196; 
Dr.  N.  F.  Cooke  on,  196. 

Chorea,  definition  of,  662  ;  diagnosis 
of,  668;  complications  in,  667;  pa- 
thology of,  663  ;  prognosis  in;  668 ; 
Dr.  Sam'l  Worcesteron,663;  symp- 
toms of,  665  ;  treatment  of,  668. 

Churchill,  Dr.,  on  bread  jelly,  56. 

Ciliaris,  acute,  94. 

Circulation,  in  infancy,  5;  Holden 
on,  5. 

Coates,  Dr.,  on  gangrene  of  mouth, 
164. 

Cod-liver  oil,  in  dj'spepsia,  178;  in- 
unctions of,  22. 

Colic,  article  on,  204;  causes.  204; 
symptoms,  205 ;  treatment  of,  20<3. 

Collapse,  hot  bath  in,  23;  of  lung,  583. 

Coloboma,  76. 

Complexion,  in  disease,  11. 

Congenital,  disease  of  heart,  387;  dys- 
pepsia, 171;  ptosis,  76. 

Congestion  of  brain,  735;  symptoms, 
736;  treatment,  738. 

Conjunctivitis,  catarrhal,  82;  chapter 
on,  82;  treatment  of,  82;  phlyctenu- 
lar, 83  ;  Dr.  Leibold  on,  85. 

Constipation,  chapter  on,  200;  pathol- 
ogy of,  203 ;  treatment  of,  202. 

Consumption,  in  nursing,  36. 

Continued  fever,  615. 

Convalescence  in  chronic  maladies, 
10. 

Convergent  strabismus,  102. 

Convulsions,  652 ;  etiology  of,  652 ; 
diagnosis,  654;  prognosis,  654;  sig- 
nificance of,  9 ;  sudden  death  from, 
11;   symptoms,  653;  treatment  of, 

655. 

Corectopia,  77. 

Cornea,  opacities  of,  93 ;  treatment 
of  94  ;  staphyloma  of,  94 ;  ulcers  of, 
86. 

Cor^'za,  chapter  on,  515;  symptoms 
of,  516;  treatment  of,  517. 

Cough,  511  ;  as  symptom,  511 ;  treat- 
ment, 512;  remedies  in,  512-514. 

Craniotabes,  240. 

Cross-eye,  102. 

Croup,  false,  534;  spasmodic,  534; 
true,  538. 

Croupous  pneumonia,  552. 


Cry,  in  disease,  12. 

Cutaneous  vs.  auditory,  impressions^ 

118. 
Cuts,  of  eye,  iii. 
Cyanosis,  388;  treatment,  389. 

D 

Daily  News  Sanitarium,  187. 

Daily  bath  in  infancy,  69. 

Dake,  Dr,  J.  P.,  on  "  Similars,"  19. 

Death,  sudden,  from  collapse  of  lung,. 
11;  from  convulsions,  11. 

Dentition,  a  cause  of  ear  disease,  122; 
eflFects  of  upon  ears,  148;  first,  222; 
order  of  eruption  during,  223;  pre- 
mature decay  of  teeth  during,  225  ; 
second,  226;  treatment  of,  226;  gum 
lancet  in  difficult,  228;  Dr.  J,  W. 
White  on,  232;  indications  for  lanc- 
ing, 230. 

Destruction  of  auditory  nerve,  139. 

Development  of  bones  in  infancy,  4 ; 
development  of  brain  in  infancy,  4; 
development  of  ear  in  infancy,  138; 
development  of  jaws,  4;  develop- 
ment of  teeth,  4. 

Diabetes,  insipidus,  489;  symptoms  of,. 
490;  urine  in,  490;  treatment  of,  492; 
mellitus,  470;  analysis  of  urine  in, 
475  ;  complications  of,  472;  diabetic 
coma,  473 ;  Stern  on,  470 ;  Schnee 
on,  470;  Kiihl  on,  470;  pathology 
of,  471 ;  sex  in,  471 ;  reports  of  cases, 
481;  symptoms,  472;  treatment  of,. 
477 ;  table  of  diet,  478 ;  electricity 
in,  479. 

Diarrhea,  chapter  on,  179;  compara- 
tive mortality  from,  184;  varieties  of, 
iSo;  complications,  186;  symptoms 
of,  186;  treatment  of,  188. 

Diathetic  diseases,  chapter  on,  233. 

Diffuse  keratitis,  91;  diffuse  nephritis^ 

439- 

Digestive  organs,  diseases  of,  152. 

Diphtheria,  chapter  on,  336;  cause  of 
death  in,  351;  complications,  360; 
etiology,  339;  contagiousness  of, 
342;  iClebs-Loffler  bacillus,  344; 
Sevestre  on,  349;  Dr.  S.  Danforth 
on,  337;  Dr.  W.  G.  Douglas  on, 
337;  Dr.  Kearsley  on,  33S;  Sir  M. 
McKenzie  on,  336;  immunity  from, 
350;  laryngeal,  358;  diagnosis,  358 ; 
symptoms  of,  356-359;  treatment  of, 
361;  intubation  in,  368;  Dr.  J.  S. 
"Mitchell  on,  364;  Dr.  E.  M.  Hale 
on,  366;  Dr.  R.  Hughes  on,  364; 
tracheotomy  in,  368. 


INDEX. 


80» 


Disease,  signs  of,  ii;  attitude  in,  12; 

complexion  in,  11;  cry  in,  12;  facial 

lines  in,  12 ;  Dr.  Eustace  Smith  on, 

12. 
Diseases,  systemic  and  general,  108. 
Diseases,    non-eruptive,    contagious, 

336. 
Diseases,  lachrymal,  99;  treatment  of, 

100. 
Disorders  of  sleep,  729;  disorders  of 

urinary  tract,  420. 
Dressing  the  baby,  directions  for,  70; 

dressing  the  navel,  67. 
Drum    membrane,    examination    of, 

117;  malformations  of,  116. 
Dysentery,    197;   diagnosis    of,    198; 

symptoms,  198;  treatment,  198. 
Dyspepsia,  congenital,  171;  diagnosis, 

176;  treatment,  177. 


Ear,  diseases  of  the,  115;  malforma- 
tion of,  115;  auricle,  115;  external 
auditory  canal,  1 16;  middle  ear,  1 16; 
examination  of,  117;  care  of  the,i2o; 
causes  of  disease  of,  121 ;  significance 
of  in  brain  diseases,  122;  diseases  of 
external,    123. 

Ear,  internal,  137;  imperfect  develop- 
ment of,  138;  diagnosis  of  diseases 
in,  138;  effect  of  destruction  of  audi- 
tory canal,  139;  treatment  of,  140; 
foreign  bodies  in,  145;  injuriesof,  150; 
removal  of  foreign  bodies  from,  150. 

Ectopia  tarsi,  76. 

Eczema,757;  etiologj'  of,  785;  varieties, 
760;  symptoms,  761 ;  pathology  of, 
764 ;  treatment  of,  764. 

Eczema  of  external  ear,  123. 

Electricity  as  a  galactagogue,  39. 

Emetics,  danger  of,  in  infants,  20. 

Emphysema,  580 ;  symptoms  of,  581 ; 
treatment  of,  582. 

Enteric  fever,  615. 

Enuresis,  494;  reflex,  495;  diurnal, 
496;  examination  of  patient  with, 
497;  treatment  of,  497  ;  miscellane- 
ous notes  on,  499;  cases  of,  500. 

Entropion,  76. 

Endocarditis,  401 ;  physical  signs  of; 
402 ;  treatment  of,  403. 

Entero-colitis,  183. 

Enteralagia,  204. 

Epilepsy,  659 ;  symptoms,  657 ;  treat- 
ment of,  658. 

Epistaxis,  519;  treatment  of,  520. 

Epidemic  meningitis,  604. 

Epicanthus,  76. 


Erythema,  777;  symptoms  of,  778;  di- 
agnosis, 779 ;  treatment,  779. 

Eruptive  fevers,  the,  272. 

Erysipelas,  784;  diagnosis  of,  787; 
symptoms,  786;  treatment  of,  788, 

Esophagitis,  165;  J.  Lewis  Smith  on, 
165;  treatment  of,  165. 

Eyes,  diseases  of  the,  in  infants,  74; 
malformations  of,  76;  vascular 
nerve,  77;  examination  of  the,  78. 


False  croup,  534.  (See  Spasmodic 
Laryngitis.) 

Farinaceous  foods,  58. 

Febrile  diarrhea,  183. 

Feeding,  artificial,  46;  with  cow's 
milk,  46 :  boiled  milk,  50 ;  human- 
ized milk,  49;  peptonized  milk,  48 ; 
sterilized  milk,  52;  "proteinol,"  52; 
Dr.  G.  W.  Winterburn's  food,  52, 

Feeding,  forced,  see  Gavage,  61;  re- 
capitulation of,  64. 

Fetal  condition  of  lung,  583;  fetal  cir- 
culation, 385. 

Fevers,  eruptive,  272. 

First  toilet,  baby's,  67. 

Flour,  wheat,  how  prepared,  56. 

Focal  sclerosis,  677. 

Follicular  stomatitis,  157.  (See  Stom- 
atitis.) 

Fontanels,  closure  of  anterior,  3 ;  pos- 
terior, 3. 

Foods  and  feeding,  32;  commercial, 
the,  57;  cereal  foods  and  their  uses, 

S3- 

Food,  artificial,  with  nursing  baby, 
44;  farinaceous,  58;  Liebig,  59; 
milk,  59;  barley  water,  54;  bread 
jelly,  56 ;  Meigs  and  Pepper's  for- 
mula, 56;  oats,  54;  wheat,  54;  wheat 
flour,  prepared,  56;  best  test  for  a 
baby,  33 ;  solid,  in  nursing,  45.  (See 
Feeding.) 

Foreign  bodies  in  ear,  150;  foreign 
bodies  in  eye,  iii. 

Fremitus,  vocal,  16. 

French  measles  (see  Rotheln),  284. 

Frequency  of  nursing,  43. 

Fruits,  eating  of,  by  nursing  women, 
40. 


Gangrene  of  mouth,  161 ;  pathology, 
162;  symptoms,  162;  prognosis,  163; 
treatment,  164;  Dr.  Coates  on,  164; 
M.  Taupin  on,  164. 

Gastric  catarrh  (see  Gastritis),  166. 


810 


INDEX. 


Gastritis,  i66 ;  causes  of,  i66;  compli- 
cations of,  167 ;  treatment  of,  168 ; 
Jahr  on,  169;  Pepper  on,  170. 

Gelatin  in  dyspepsia,  178. 

General  diseases,  consideration  of, 
604. 

Gerber's  food,  analysis  of,  59. 

German  measles  (see  R6theln),284. 

Gertrude  suit,  the,  67. 

Glasses,  the  use  of,  105;  selection  of, 
107. 

Glioma  of  the  retina,  107;  diagnosis, 
113;  treatment,  114. 

Growth  of  infants,  7. 

H 

Harelip,  35. 

Hawley's  food,  analysis  of,  59. 

Headache  in  children,  733;  treatment 

of,  734- 

Heart,  affections  of  the,  383 ;  method 
of  study,  384 ;  fetal  circulation,  385  ; 
Leavitt  on,  385;  Keating  on,  386; 
congenital  disease  of,  387;  diagnosis 
of,  388;  valvular  disease  of  heart, 
390;  Dr.  E.  A,  Neatly  on,  390; 
symptoms  of  valvular  disease,  393; 
tricuspid,  392 ;  aortic  insufficiency, 
393;  Corrigan  on,  393;  complica- 
tions of,  394;  treatment  of,  395;  en- 
docarditis, 401  ;  pericarditis,  405; 
myocarditis,  409;  general  consider- 
ations for  remedies,  410. 

Hearing  in  infancy,  118;  auditorj' 
center,  119;  sound  vs.  motion,  120. 

Height  of  children,  table  of,  8. 

Hematuria,  451;  differential  diagnosis 
of,  451. 

Hemorrhage,  cerebral,  679;  symp- 
toms, 680;  diagnosis,  681 ;  prog- 
nosis, 682 ;  treatment,  683. 

Hemorrhage,  spinal,  700 ;  treatment, 
701. 

Hemorrhage,  umbilical,  29;  symp- 
toms, 30;  treatment,  31. 

Herpes  zoster,  781.     (See  Zoster.) 

Hints,  nursing,  66. 

Hints,  therapeutic,  19 

Hives  (see  Urtacaria),  793;  symptoms, 
794;  treatment,  795. 

Heterophoria,  104;  etiology  of,  105; 
treatment,  105. 

Hordeolum,  98;  etiology,  99;  treat- 
ment, 99. 

Hot  bath,  23. 

Holden  on  infantile  circulation,  5. 

Houghton,  H.  C,  on  aural  remedies, 
141. 


Holland,   Sir    Henry,   on   dyspepsia, 

176. 
Hubbell's  wheat  food,  analysis  of,  58. 
Hydronephrosis,   459;    treatment  of, 

459- 

Hj'drocephalus,  750;  acquired,  752; 
congenital,  751;  sj-mptoms,  752; 
prognosis,  754;  treatment,  755. 

Hysteria,  721 ;  symptoms,  723;  diag- 
nosis, 725 ;  treatment,  726. 

Hypertrophy  of  tonsils  (see  Tonsilitis, 
chronic),  539. 


Idiocy,  713;  diagnosis  of,  714;  treat- 
ment of,  715. 

Impetigo  contagiosa,  790. 

Imperfect  development  of  ear,  138. 

Incontinence  of  urine,  494. 

Infancy,  anatomical  peculiarities  of, 
2;  weight  in,  3;  nervous  system  in, 
3;  glandular  system  in,  4;  circula- 
tion in,  5;  hearing  in,  118;  use  of 
alcohol  in,  21  ;  anodynes  in,  22. 

Infantile  remittent  fever  (see  Ty- 
phoid), 615. 

Infantile  paralj'sis,  696. 

Infantile  syphilis,  269. 

Infantile  tetanus,  672. 

Inflammation  of  stomach,  166. 

Inflammation  of  tonsils,  524. 

Inflammation  of  middle  ear,  124. 

Inflammatory  diarrhea,  183. 

Injuries  of  ear,  150. 

Injuries  of  eye,  no. 

Insanity,  718;  diagnosis  and  prog- 
nosis, 720;  symptoms,  719. 

Insects  in  ear,  150. 

Interstitial  keratitis,  91, 

Intestinal  catarrh,  183. 

Intestinal  obstruction,  218. 

Intestinal  parasites,  207 ;  sj'mptoms 
of,  211;  treatment  of,  212;  ascarides 
lumbricoides,  213;  ox^'uris  vermi- 
culosis,  208 ;  tenia,  209. 

Intussusception,  218;  pathology,  219; 
prognosis,  220;  symptoms  of,  219; 
treatment  of,  220. 

Itch  (see  Scabies),  802,- 


J 


Jacobi.  Dr.,  on  feeding,  34. 
Jahr,  on  gastritis,  169. 
Jelly,  bread,  56. 
Juice,  raw-meat,  60. 


INDEX. 


811 


K 

Keasbey  and  Mattison's  food,  analy- 
sis of,  59. 

Keratitis,  diffuse,  91;  diagnosis,  91; 
symptoms,  91;  prognosis,  92;  treat- 
ment, 92;  marginal,  87. 

Kidney,  scrofulous,  460;  tuberculosis 
of,  459;  Kuhl  on,  470. 


Laceration  of  eye,  iii. 

Lachrymal  disease,  99. 

Larrabee,  Dr.  J.  A.,  on  diabetes,  470. 

Laryngismus  stridulus,  536;  treat- 
ment, 537. 

Laryngitis,  acute  membranous,  538; 
season,  539;  pathology  of,  545;).  S. 
Mitchell  on,  541 ;  complications  of, 
544;  prognosis,  547  ;  diagnosis,  546; 
treatment  of,  548;  chronic,  535 ; 
symptoms,  535. 

Larj'ngitis,  spasmodic,  534;  diagnosis, 
535 ;  treatment,  535. 

Leibig's  foods,  analysis  of,  59. 

Leibold,  Dr.,  on  conjunctivitis,  85. 

Lines,  facial,  12. 

Liver  in  infancy,  4;  situation  of,  4; 
weight  of,  4. 

Lobar  pneumonia,  552  ;  lobular  pneu- 
monia, 552. 

Lockjaw  (see  Tetanus),  672. 

Lung  fever  (see  Pneumonitis),  552. 

Luxatio  lentis  congenitalis,  77. 

Lymphatics,  in  infancy,  4. 

M 

Malformation  of  eye,  76. 

Malignant  meningitis,  604. 

Marasmus,  pathology  of,  10. 

Mastoid  disease,  10. 

Mastoid  process  at  birth,  117. 

McClellan  on  thymus,  4. 

Measles,  276;  eruption  in,  277;  vari- 
eties, 278;  complications,  279 
symptoms,  276;  diagnosis,  280 
prognosis,  281 ;  sequela,  280 ;  mor 
tality,  table  of,  283;  treatment,  282. 

Measles,  French,  284;  German,  284. 

Meat  juice,  raw,  60. 

Meat  preparations,  6o. 

Meigs  and  Pepper's  formula,  56. 

Melltn's  food,  analysis  of,  59. 

Meningitis,  741;  effects  of  on  ears, 
147  ;  pathology,  742  ;  prognosis  in, 
743  >  symptoms,  742 ;  treatment, 
748;  tubercular,  744 ;  sj'mptoms  of, 
745;  diagnosis,  746;  treatment,  748. 


Menstruation,  effect  of  on   nursing. 

Mercury,  effect  of  in  infancy,  20. 

Milk,  asses',  51 ;  cow's,  analysis  of,  50; 
boiled,  50;  foods,  analysis  of,  59; 
goats',  51 ;  human,  51 ;  humanized, 
49;  Cheadle  on,  49 ;  peptonized,  48; 
scantiness  of  in  anemia,  38;  steril- 
ized,  53. 

Morbilli  (see  Measles),  276. 

Mouth,  gangrene  of,  161. 

Muguet  (see  Thrush),  159. 

Mumps,  380. 

Murdock's  food,  analysis  of,  59. 

Murmurs,  cardiac,  16;  respiratory,  15. 

Myelitis,  693 ;  treatment,  694 ;  an- 
terior polyomyelitis,  696;  cause  of, 
697  ;  diagnosis,  698;  treatment,  699; 
chronic,  695;  treatment  of,  696. 

Myocarditis,  409;  treatment  of,  410. 

Myopia,  requiring  glasses,  106. 

N 

Nasal  catarrh  (see  Coryza),  515. 

Navel,  dressing  of  the,  67. 

Nephritis,  acute,  439;  complications, 
446;  urine  in,  448 ;  diarrhea  in,  448; 
course  of,  442;  prognosis,  443; 
symptoms,  439;  treatment  of,  443 ; 
sub-acute,  448;  analysis  of  urine  in, 
450;  duration  of,  448;  pathology, 
449;  treatment,  449. 

Nettle  rash  (see  Hives),  793. 

Nervous  system,  affections  of,  647 ; 
general  remarks  on  diagnosis  of, 
648. 

Nestle's  food,  analysis  of,  59. 

Night  terrors,  731 ;  symptoms  and 
treatment,  731. 

Nipple,  retracted,  36. 

Noma  (see  Gangrene  of  Mouth),  161. 

Non -eruptive  contagious  diseases,  336. 

Nurse,  wet,  selection  of,  41. 

Nursing,  directions  for,  43 ;  diseases 
contraindicating,  35;  effect  of  men- 
struation on,  37;  effect  of  preg- 
nancy on,  37 ;  rickets  as  a  result  of, 

38. 
Nutrolactis,  analysis  of,  59;  effect  of, 

59- 

o 

Oats  as  a  baby  food,  54. 

Opacitus  of  cornea,  93. 

Ophthalmia  neonatorum,  78;  cause  of, 
79;  symptoms  of,  79;  prognosis  and 
treatment  of,  81;  phlyctenular,  87; 
tarsi,  94. 


812 


INDEX. 


Opium,  efTect  of  on  infants,  20. 
Orthophoria,  104, 
Osseous  system,  in  infancy,  20. 
Otitis  media,  acute,  124. 
Oxyuris  vermiculosis,  208. 


Paralysis,  675  ;  diagnosis,  676;  prog- 
nosis, 677;  cerebro-spinal,  multiple, 
677 ;  diagnosis  and  prognosis,  678; 
treatment,  679;  spinal,  690;  treat- 
ment, 691  ;  pseudo  -  h^'pertrophic, 
702;  prognosis  and  treatment,  703; 
of  the  portio  dura,  703;  prognosis 
and  treatment,  705. 

Pack,  wet  sheet,  use  of,  24. 

Paraphlegia,  spastic,  701. 

Parasites,  intestinal,  207. 

Parolitis,  380. 

Parotiditis,  380;  symptoms  of,  381 ; 
diagnosis  of,  382  ;  treatment  of,  382. 

Parrot,  on  24-hours'  urine  of  infants, 
420. 

Palate,  cleft,  35. 

Pericarditis,  405  ;  pathology  of,  406 ; 
prognosis  in,  407. 

Pertussis  (see  Whooping  Cough),  371. 

Phthisis,  pulmonary,  588 ;  pathology, 
589;  complications,  590;  treatment. 

Pleurisy,  595;  symptoms,  596;  physi- 
cal signs,  598;  diagnosis,  600;  prog- 
nosis and  treatment,  601. 

Pneumonitis,  552;  pathology,  553; 
clinical  history,  556;  physical  signs, 
.S57;  diagnosis,  559;  prognosis,  560; 
treatment,  562. 

Polycoria,  77. 

Porrigo,  contagiosa,  790;  treatment, 
791. 

Pott's  disease,  693;  treatment,  693. 

Psoriasis,  771 ;  pathology,  772;  treat- 
ment, 773. 

Ptosis,  congenital,  76. 

Pupillary  membrane,  persistent,  77. 

Pyuria,  451;  differential  diagnosis  of, 
452- 

Pseudo-membranous  laryngitis,  538. 

Q 

Quinsy  (see  Tonsilitis),  524. 

R 

Rachitis,  235 ;  causes,  236;  pathology 
of,  238 ;  first  stage,  238 ;  second 
stage,  240;  third  stage,  242 ;  symp- 
toms, 243;  complications,  245; 
treatment,  246. 


Respiratory  organs,  diseases  of,  508. 

Respiration  in  infancy,  abdominal,  3; 
Cheyne- Stokes,  6;  puerile,  16;  apex^ 
16. 

Red-gum  (see  Strophulus),  775. 

Retro- pharyngeal  abscess,  532;  treat- 
ment, 533". 

Rheumatism,  63S;  symptoms,  639; 
treatment,  640. 

Ridge's  food,  analysis  of,  58. 

Ringworm,  79S;  treatment,  800. 

Robinson's  patent  barley,  58. 

Roseola,  317;  symptoms,  318;  diag- 
nosis, 319;  differential  table  of,  320; 
treatment,  319. 

Rotheln,  284;  duration  of,  285;  symp- 
toms, 285;  diagnosis,  286;  differ- 
ential table  of,  320;  treatment,  288. 

Rubella  (see  Rotheln),  284. 

Rubella  (see  Measles),  276. 


Savory  and  Moore's  food,  analysis  of, 

59- 

Scabies  (see  Itch),  802;  treatment  of, 
805. 

Scarlet  fever,  289;  regular,  290;  irreg- 
ular, 294;  malignant,  296;  compli- 
cations, 297;  symptoms,  298;  diag- 
nosis, 300;  differential  table  of,  320; 
duration  of,  301 ;  mortality  from, 
302;   prophylaxis,  303;    treatment, 

305- 

Sclerosis,  primary  lateral,  701;  treat- 
ment, 701. 

Sclerosis,  multiple  cerebro-spinal  (see 
Paralj-sis),  677. 

Scrofula,  257  ;  pathology,  258 ;  diag- 
nosis and  symptoms,  259;  treat- 
ment, 261. 

Sleep,  disorders  of,  729;  causes  of  dis- 
turbed, 730;  treatment,  730. 

Sprue   (see   Stomatitis,  Thrush),  159. 

Stomach,  inflammation  of  (see  Gas- 
tritis), 166. 

Stomatitis,  chapter  on,  153;  simple  or 
catarrhal,  153;  symptoms,  154;  ul- 
cerous, 155;  treatment,  156;  folli- 
cular (apthjE),  157;  symptoms,  158; 
treatment,  159;  thrush,  159;  symp- 
toms, 160;  treatment,  161;  gangre- 
nous, 161. 

Strabismus,  102;  treatment,  103. 

Suit,  the  Gertrude,  67. 

St.  Vitus'  dance  (see  Chorea),  662. 

Strophulus.  775;  diagnosis,  776;  treat- 
ment, 776. 

Syphilis,  infantile,  267;  symptoms, 
268 ;  treatment,  270. 


INDEX. 


813 


Tabes  mesenterica  (see  Tuberculosis), 

253- 

Tetanus,  infantile,  672 ;  symptoms, 
673 ;  treatment,  674. 

Typhoid  fever,  infantile,  615;  symp- 
toms, 617;  pathology,  619;  diag- 
nosis, 620;  treatment,  621. 

Tonsilitis,  524;  etiology  of,  525;  symp- 
toms, 526;  course,  528;  treatment, 

529- 
Tonsilitis,  chronic,  529;  etiology,  530; 

symptoms,  531;  treatment,  531. 
Trichophj'tosis  (see  Ringworm),  798; 

treatment  of,  800. 
Trismus   nascentium    (see   Tetanus), 

672. 
Tuberculosis,  acute,  250;  etiology  of, 

251;  symptoms  of,   252;  treatment 

of,    253;    tabes     mesenterica,   253; 

symptoms  of,  254 ;  treatment,  255. 
Tumors,  cerebral,  684;  varieties,  685  ; 

localization  of,  686;  treatment  of, 

689. 
Tussis     convulsiva     (see    Whooping 

Cough),  371. 


U 


Ulcers  of  cornea   (see    Cornea),  86; 

phlyctenular,  87 ;  treatment,  88. 
Urea  of  infants   and   children,   423; 

quantity  in  24  hours,  423. 


Urine,  the,  of  infancy  and  childhood, 
420;  clinical  notes  on,  421;  reaction, 
422 ;  of  the  new  born,  433. 

Urine,  the,  in  various  disorders  of 
childhood,  435 ;  fevers,  435;  typhoid 
fever,  435;  whooping  cough,  436; 
measles,  437. 

Uricemia,  464;  urine  in,  467;  treat- 
ment, 467. 

Urticaria  (see  Hives),  793;  symptoms, 
794;  treatment,  795. 


Vaccinia,  328 ;  Dr.  W.  T.  Plant  on, 

329- 

Vaccination,  330;  methods  of,  331; 
painless,  331;  symptoms  and  course, 
332;  complications,  333  ;  after-treat- 
ment of,  334. 

Varicella,  322 ;  diagnosis,  323;  treat- 
ment, 328. 

w 

Weaning,  indications  for,  38. 

Wet  nurse,  selection  of,  41. 

Weight  of  infants  at  birth,  8. 

Whooping  cough,  371 ;  symptoms, 
371;  complications,  374;  diagnosis, 
375 ;  mortality  in,  376;  treatment, 
376. 

z 

Zoster,  781;  symptoms,  782;  treat- 
ment, 783. 


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Tooker,  Robert  N, 

Diseases  of  children  and 
their  homeopathic  treatment 


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Tooker,  Robert  N. 
Diseases  of  Children  and  their 

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